Healthcare Provider Details

I. General information

NPI: 1467217372
Provider Name (Legal Business Name): PSYCHOGENESIS DETOX CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 AIRWAY AVE STE C3
COSTA MESA CA
92626-4622
US

IV. Provider business mailing address

30912 STEEPLECHASE DR
SAN JUAN CAPISTRANO CA
92675-1928
US

V. Phone/Fax

Practice location:
  • Phone: 949-769-1372
  • Fax:
Mailing address:
  • Phone: 949-769-1372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. NADER BABAI SIAHDOHONI
Title or Position: CEO
Credential: PHD
Phone: 949-769-1372