Healthcare Provider Details

I. General information

NPI: 1154847838
Provider Name (Legal Business Name): GRAND TERRACE DETOX AND RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18989 GRAND AVE
LAKE ELSINORE CA
92530-6259
US

IV. Provider business mailing address

18989 GRAND AVE
LAKE ELSINORE CA
92530-6259
US

V. Phone/Fax

Practice location:
  • Phone: 954-210-8617
  • Fax: 954-982-2827
Mailing address:
  • Phone: 954-210-8617
  • Fax: 954-982-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number330168AP
License Number StateCA

VIII. Authorized Official

Name: ERIC MCCOY
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 954-446-3538