Healthcare Provider Details

I. General information

NPI: 1982957197
Provider Name (Legal Business Name): BALBOA RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 VIA LIDO
NEWPORT BEACH CA
92663-3908
US

IV. Provider business mailing address

204 21ST ST
NEWPORT BEACH CA
92663-4372
US

V. Phone/Fax

Practice location:
  • Phone: 949-723-2388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: KEVIN CULLEN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 949-400-7120