1619372380 NPI number — MYLIFE RECOVERY CENTERS, A MEDICAL CORP.

Table of content: (NPI 1619372380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619372380 NPI number — MYLIFE RECOVERY CENTERS, A MEDICAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYLIFE RECOVERY CENTERS, A MEDICAL CORP.
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:
1619372380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10061 RIVERSIDE DR
Provider Second Line Business Mailing Address:
#874
Provider Business Mailing Address City Name:
TOLUCA LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91602-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-736-5836
Provider Business Mailing Address Fax Number:
818-736-5846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 LA CASA VIA
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94598-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-201-6400
Provider Business Practice Location Address Fax Number:
818-736-5846
Provider Enumeration Date:
10/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LAI
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
818-736-5836

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084A0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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