Healthcare Provider Details

I. General information

NPI: 1164837670
Provider Name (Legal Business Name): ALTADENA RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 LINCOLN AVE
ALTADENA CA
91001-4534
US

IV. Provider business mailing address

3025 LINCOLN AVE
ALTADENA CA
91001-4534
US

V. Phone/Fax

Practice location:
  • Phone: 626-765-6905
  • Fax: 626-765-6905
Mailing address:
  • Phone: 626-765-6905
  • Fax: 626-765-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHIRLEY ANN BENNETT
Title or Position: DIRECTOR
Credential: R.A.S.
Phone: 661-974-5285