MEDICARE: LONG BEACH RECOVERY, INC.

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	:	1174925549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG BEACH RECOVERY, INC.

Provider Business Mailing Address
First Line	:	2900 BRISTOL ST STE B300
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-5948
Country	:	US
Telephone Number	:	949-467-9213
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 E APPLETON ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-3911
Country	:	US
Telephone Number	:	949-467-9213
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	STEVE FENNELLY
Credential	:
Telephone Number	:	949-467-9213

Provider Enumeration Date	:	09/17/2014
Last Update Date	:	09/17/2014

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