Healthcare Provider Details

I. General information

NPI: 1568024263
Provider Name (Legal Business Name): INTEGRATED RECOVERY FOUNDATION 22
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30211 AVENIDA DE LAS BANDERA STE 200
RANCHO SANTA MARGARITA CA
92688-2159
US

IV. Provider business mailing address

25 FLOR AMOR
RANCHO SANTA MARGARITA CA
92688
US

V. Phone/Fax

Practice location:
  • Phone: 949-533-6075
  • Fax: 949-484-7021
Mailing address:
  • Phone: 951-813-1720
  • Fax: 949-484-7021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MYRNA B FERNANDEZ
Title or Position: UR/BILLING
Credential: LPT
Phone: 951-813-1720