Healthcare Provider Details

I. General information

NPI: 1487950002
Provider Name (Legal Business Name): CHEMICAL DEPENDENCY & PAIN RECOVERY OF CA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 JUTLAND DR SUITE 103
SAN DIEGO CA
92117-3663
US

IV. Provider business mailing address

4241 JUTLAND DR SUITE 103
SAN DIEGO CA
92117-3663
US

V. Phone/Fax

Practice location:
  • Phone: 858-490-3460
  • Fax: 858-490-3462
Mailing address:
  • Phone: 858-490-3460
  • Fax: 858-490-3462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number370123BP
License Number StateCA

VIII. Authorized Official

Name: MR. JAMES REED
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 858-490-3460