Healthcare Provider Details

I. General information

NPI: 1346153905
Provider Name (Legal Business Name): TRADE RECOVERY CENTER - OUTPATIENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5112 BULLION ST
MARIPOSA CA
95338
US

IV. Provider business mailing address

PO BOX 543
MARIPOSA CA
95338-0543
US

V. Phone/Fax

Practice location:
  • Phone: 209-742-5095
  • Fax:
Mailing address:
  • Phone: 209-742-5095
  • 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: LISA PARKER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 209-291-1889