MEDICARE: MILESTONE 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1164888442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILESTONE DETOX, LLC

Provider Business Mailing Address
First Line	:	1040 W 17TH ST
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-4503
Country	:	US
Telephone Number	:	949-388-4114
Fax Number	:	949-203-8540

Provider Business Practice Location Address
First Line	:	31981 CALLE WINONA
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3076
Country	:	US
Telephone Number	:	949-344-8149
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. SHAWN WHITT
Credential	:
Telephone Number	:	949-344-8149

Provider Enumeration Date	:	01/03/2016
Last Update Date	:	01/18/2019

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