Healthcare Provider Details

I. General information

NPI: 1730436809
Provider Name (Legal Business Name): BALBOA RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3206 W BALBOA BLVD
NEWPORT BEACH CA
92663-3018
US

IV. Provider business mailing address

3419 VIA LIDO
NEWPORT BEACH CA
92663-3908
US

V. Phone/Fax

Practice location:
  • Phone: 949-400-7120
  • Fax:
Mailing address:
  • Phone: 949-400-7120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN CULLEN
Title or Position: PRESIDENT CEO
Credential:
Phone: 949-400-7120