1497414379 NPI number — CRESCENT MOON RECOVERY, LLC

Table of content: (NPI 1497414379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497414379 NPI number — CRESCENT MOON RECOVERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESCENT MOON 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:
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:
1497414379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18652 FLORIDA ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92648-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-464-8474
Provider Business Mailing Address Fax Number:
714-948-8883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18652 FLORIDA ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92648-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-464-8474
Provider Business Practice Location Address Fax Number:
714-948-8883
Provider Enumeration Date:
12/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WADE
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
661-706-8898

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CLR-90002425 . This is a "CDPH CLIA LICENSE, STATE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 300398AP . This is a "CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES, OUTPATIENT CERTIFICATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 661764 . This is a "THE JOINT COMMISSION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05D2207074 . This is a "CLINICAL AND PUBLIC HEALTH LABORATORY LICENSE, CLIA ID" identifier . This identifiers is of the category "OTHER".




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