Healthcare Provider Details

I. General information

NPI: 1740742840
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

317 ROCHESTER ST
COSTA MESA CA
92627-3113
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 TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

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