Healthcare Provider Details

I. General information

NPI: 1164466785
Provider Name (Legal Business Name): LAGUNA BEACH REHAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 AVOCADO AVE STE 307
NEWPORT BEACH CA
92660-7704
US

IV. Provider business mailing address

1441 AVOCADO AVE STE 307
NEWPORT BEACH CA
92660-7704
US

V. Phone/Fax

Practice location:
  • Phone: 949-640-2121
  • Fax: 949-640-2631
Mailing address:
  • Phone: 949-640-2121
  • Fax: 949-640-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberBT00015281
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN R FRACALOSY
Title or Position: H.R. MANAGER
Credential:
Phone: 949-640-2121