Healthcare Provider Details

I. General information

NPI: 1518429612
Provider Name (Legal Business Name): HOTEL CALIFORNIA BY THE SEA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E 17TH ST STE 201
COSTA MESA CA
92627-3891
US

IV. Provider business mailing address

2811 VILLA WAY
NEWPORT BEACH CA
92663-3728
US

V. Phone/Fax

Practice location:
  • Phone: 800-762-6717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation 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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN MELLO
Title or Position: PRESIDENT
Credential:
Phone: 800-762-6717