Healthcare Provider Details

I. General information

NPI: 1104740133
Provider Name (Legal Business Name): PRIVATE SOLUTION DETOX CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72301 COUNTRY CLUB DR STE 113
RANCHO MIRAGE CA
92270-8007
US

IV. Provider business mailing address

72301 COUNTRY CLUB DR STE 200
RANCHO MIRAGE CA
92270-8007
US

V. Phone/Fax

Practice location:
  • Phone: 833-773-3869
  • Fax: 760-895-4497
Mailing address:
  • Phone: 833-773-3869
  • Fax: 760-895-4497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: EMILIO ANGULO
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 833-773-3869