1902405749 NPI number — CRC HEALTH TREATMENT CLINICS, LLC

Table of content: (NPI 1902405749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902405749 NPI number — CRC HEALTH TREATMENT CLINICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRC HEALTH TREATMENT CLINICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902405749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6183 PASEO DEL NORTE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92011-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-259-2288
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4553 WATKINS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PACE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32571-2511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-438-7640
Provider Business Practice Location Address Fax Number:
904-438-7656
Provider Enumeration Date:
10/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
FARLEY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
PHILLIP
Authorized Official Title or Position:
VP & SECRETARY
Authorized Official Telephone Number:
615-716-9335

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 015839101 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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