Healthcare Provider Details

I. General information

NPI: 1215582234
Provider Name (Legal Business Name): SO CAL RECOVERY CENTERS DP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44267 MONTEREY AVE STE A&B
PALM DESERT CA
92260-2755
US

IV. Provider business mailing address

34249 CAMINO CAPISTRANO STE 101
CAPISTRANO BEACH CA
92624-1156
US

V. Phone/Fax

Practice location:
  • Phone: 949-481-6156
  • Fax: 949-542-3878
Mailing address:
  • Phone: 949-481-6156
  • Fax: 949-542-3878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. LINDSEY MYERS
Title or Position: CEO
Credential:
Phone: 949-481-6156