MEDICARE: 1545 NEWPORT BOULEVARD 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1184572216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1545 NEWPORT BOULEVARD LLC

Provider Business Mailing Address
First Line	:	1545 NEWPORT BLVD
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-3714
Country	:	US
Telephone Number	:	949-659-6777
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 NEWPORT BLVD
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-3714
Country	:	US
Telephone Number	:	949-659-6777
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	ANDREA BROWN
Credential	:
Telephone Number	:	949-659-6777

Provider Enumeration Date	:	03/16/2026
Last Update Date	:	03/16/2026

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