Healthcare Provider Details

I. General information

NPI: 1619661576
Provider Name (Legal Business Name): NEW ROUTE RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 BONNIE HILL DR
LOS ANGELES CA
90068-1322
US

IV. Provider business mailing address

1968 S COAST HWY STE 2839
LAGUNA BEACH CA
92651-3681
US

V. Phone/Fax

Practice location:
  • Phone: 424-478-1336
  • Fax: 213-995-8716
Mailing address:
  • Phone: 424-478-1336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH DESIDERIO
Title or Position: MGR
Credential:
Phone: 424-478-1336