Healthcare Provider Details

I. General information

NPI: 1639789035
Provider Name (Legal Business Name): PACIFIC MANOR RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3686 PACIFIC AVE
RIVERSIDE CA
92509-1948
US

IV. Provider business mailing address

3151 AIRWAY AVE STE E1
COSTA MESA CA
92626-4620
US

V. Phone/Fax

Practice location:
  • Phone: 888-700-5053
  • Fax: 949-209-5490
Mailing address:
  • Phone: 888-700-5053
  • Fax: 949-209-5490

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: TANISHA PORRECA
Title or Position: ASSISTANT TO CEO
Credential:
Phone: 828-773-4477