MEDICARE: EMPIRE HOTEL ALCOHOLIC REHABILITION 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	450001AN	CA
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	450001BN	CA

General Provider Information

NPI Number	:	1619178514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPIRE HOTEL ALCOHOLIC REHABILITION INC.

Provider Business Mailing Address
First Line	:	1237 CALIFORNIA ST
Second Line	:
City	:	REDDING
State	:	CA
Zip	:	96001-0618
Country	:	US
Telephone Number	:	530-243-7470
Fax Number	:	530-243-7477

Provider Business Practice Location Address
First Line	:	5014 SHASTA DAM BLVD.
Second Line	:
City	:	SHASTA LAKE CITY
State	:	CA
Zip	:	96019-0777
Country	:	US
Telephone Number	:	530-275-1076
Fax Number	:	530-275-3717

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	PATRICIA A NEALY
Credential	:	CASII CADCII
Telephone Number	:	530-243-7470

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	08/22/2020

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