Healthcare Provider Details

I. General information

NPI: 1861972325
Provider Name (Legal Business Name): RESURGENCE CALIFORNIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 PIERCE AVE
COSTA MESA CA
92626-2827
US

IV. Provider business mailing address

3151 AIRWAY AVE STE E1
COSTA MESA CA
92626-4620
US

V. Phone/Fax

Practice location:
  • Phone: 888-700-5053
  • Fax:
Mailing address:
  • Phone: 888-700-5053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: TANISHA PORRECA
Title or Position: COO
Credential:
Phone: 888-700-5053