1467209726 NPI number — LA COSTA RECOVERY LLC

Table of content: (NPI 1467209726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467209726 NPI number — LA COSTA RECOVERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA COSTA RECOVERY 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:
1467209726
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34249 CAMINO CAPISTRANO STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPISTRANO BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92624-1156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
136 E JASON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-1671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-359-5669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2024

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMIN
Authorized Official Telephone Number:
949-359-5669

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 370238AP . This is a "DEPARTMENT OF HEALTH CARE SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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