Healthcare Provider Details

I. General information

NPI: 1891320099
Provider Name (Legal Business Name): REFRESH RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2020
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 JUTLAND DR STE 110
SAN DIEGO CA
92117-3658
US

IV. Provider business mailing address

7660 FAY AVE # H205
LA JOLLA CA
92037-0021
US

V. Phone/Fax

Practice location:
  • Phone: 619-455-1318
  • Fax:
Mailing address:
  • Phone: 858-455-1318
  • Fax:

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 Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DANIEL SIMONS
Title or Position: CEO
Credential:
Phone: 619-455-1318