Healthcare Provider Details

I. General information

NPI: 1477220283
Provider Name (Legal Business Name): FRED BROWN'S RECOVERY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2021
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S PACIFIC AVENUE SUITE# 103-106, 203-206
SAN PEDRO, CA 90731 CA
90731
US

IV. Provider business mailing address

PO BOX 2743
SAN PEDRO CA
90731-0182
US

V. Phone/Fax

Practice location:
  • Phone: 310-519-8723
  • Fax: 310-517-1309
Mailing address:
  • Phone: 310-519-8723
  • Fax: 310-519-1309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELITA FERNANDO
Title or Position: ADMINISTRATIVE MANAGER
Credential:
Phone: 310-519-8723