MEDICARE: CAPO COAST DETOX LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1164385225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPO COAST DETOX LLC

Provider Business Mailing Address
First Line	:	21263 DOUBTFUL CANYON DR
Second Line	:
City	:	CYPRESS
State	:	TX
Zip	:	77433-8470
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34405 VIA GOMEZ
Second Line	:
City	:	CAPISTRANO BEACH
State	:	CA
Zip	:	92624-1318
Country	:	US
Telephone Number	:	949-359-5669
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	MATTHEW LEE
Credential	:
Telephone Number	:	619-987-8078

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	01/12/2026

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Directions to “CAPO COAST DETOX LLC ” Practice Location

Language	Start Address	Practice Location

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