MEDICARE: BEACHSIDE RECOVERY 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	324500000X	Substance Abuse Rehabilitation Facility	300315HP	CA

General Provider Information

NPI Number	:	1699283556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHSIDE RECOVERY LLC

Provider Business Mailing Address
First Line	:	PO BOX 511330
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90051-7885
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1332 N CUSTER ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92701-2506
Country	:	US
Telephone Number	:	949-393-4070
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	PATRICK SMITH
Credential	:
Telephone Number	:	949-393-4070

Provider Enumeration Date	:	01/12/2018
Last Update Date	:	01/12/2018

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