Healthcare Provider Details

I. General information

NPI: 1700626629
Provider Name (Legal Business Name): ADDICTION SPECIALIST OF SOUTHERN CALIFORNIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MACARTHUR BLVD SUITE 600 EAST TOWER
NEWPORT BEACH CA
92660-2517
US

IV. Provider business mailing address

66 ENGLISH SADDLE
IRVINE CA
92602-1839
US

V. Phone/Fax

Practice location:
  • Phone: 949-390-4730
  • Fax: 949-627-8107
Mailing address:
  • Phone: 949-390-4730
  • Fax: 949-627-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LAWRENCE VERNON TUCKER
Title or Position: OWNER
Credential: M.D.
Phone: 949-390-4730