Healthcare Provider Details

I. General information

NPI: 1023946431
Provider Name (Legal Business Name): TIDAL FORGE RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9582 PEPPERTREE DR
HUNTINGTON BEACH CA
92646-7550
US

IV. Provider business mailing address

9582 PEPPERTREE DR
HUNTINGTON BEACH CA
92646-7550
US

V. Phone/Fax

Practice location:
  • Phone: 442-216-1187
  • Fax:
Mailing address:
  • Phone: 442-216-1187
  • 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: MR. JAMES CODY CRAWFORD
Title or Position: EXECUTIVE DIRECTOR
Credential: CADC-II
Phone: 442-216-1187