Healthcare Provider Details

I. General information

NPI: 1417143280
Provider Name (Legal Business Name): CRC CALIFORNIA RD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20600 EAGLEPASS DR
MALIBU CA
90265-5211
US

IV. Provider business mailing address

PO BOX 2911
MALIBU CA
90265-7911
US

V. Phone/Fax

Practice location:
  • Phone: 310-589-2090
  • Fax: 310-589-5040
Mailing address:
  • Phone: 310-589-2090
  • Fax: 310-589-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number198205839
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number198205839
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number198205839
License Number StateCA

VIII. Authorized Official

Name: MR. ANDREW YOUNG
Title or Position: DIRECTOR OF OPERATIONS
Credential: LMFT
Phone: 310-589-2090