MEDICARE: DESTINY RECOVERY CENTER IOP

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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	300377AP	CA

General Provider Information

NPI Number	:	1356860738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINY RECOVERY CENTER IOP

Provider Business Mailing Address
First Line	:	23041 AVENIDA DE LA CARLOTA STE 280
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-1531
Country	:	US
Telephone Number	:	877-706-2650
Fax Number	:

Provider Business Practice Location Address
First Line	:	23041 AVENIDA DE LA CARLOTA STE 280
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-1531
Country	:	US
Telephone Number	:	877-706-2650
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MORDECHAI RUBIN
Credential	:
Telephone Number	:	877-706-2650

Provider Enumeration Date	:	09/17/2017
Last Update Date	:	09/17/2017

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