1700626629 NPI number — ADDICTION SPECIALIST OF SOUTHERN CALIFORNIA, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700626629 NPI number — ADDICTION SPECIALIST OF SOUTHERN CALIFORNIA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADDICTION SPECIALIST OF SOUTHERN CALIFORNIA, INC.
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:
1700626629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 ENGLISH SADDLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92602-1839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-390-4730
Provider Business Mailing Address Fax Number:
949-627-8107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
SUITE 600 EAST TOWER
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92660-2517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-390-4730
Provider Business Practice Location Address Fax Number:
949-627-8107
Provider Enumeration Date:
05/29/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
VERNON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
949-390-4730

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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