Healthcare Provider Details

I. General information

NPI: 1164980603
Provider Name (Legal Business Name): SAN FERNANDO RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 GRISWOLD AVE
SAN FERNANDO CA
91340-2105
US

IV. Provider business mailing address

762 GRISWOLD AVE
SAN FERNANDO CA
91340-2105
US

V. Phone/Fax

Practice location:
  • Phone: 747-500-9405
  • Fax:
Mailing address:
  • Phone: 747-500-9405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JOSE MARTINEZ
Title or Position: DIRECTOR
Credential:
Phone: 818-809-8868