MEDICARE: RESURGENCE CALIFORNIA, 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)

General Provider Information

NPI Number	:	1700586484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESURGENCE CALIFORNIA, LLC

Provider Business Mailing Address
First Line	:	3151 AIRWAY AVE STE E1
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-4620
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3151 AIRWAY AVE STE E2
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-4620
Country	:	US
Telephone Number	:	888-700-5053
Fax Number	:

Authorized Official
Title or Position	:	COMPLIANCE
Name	:	CAMILLE L LINARES
Credential	:
Telephone Number	:	949-245-5411

Provider Enumeration Date	:	03/09/2023
Last Update Date	:	03/09/2023

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