Healthcare Provider Details

I. General information

NPI: 1821796103
Provider Name (Legal Business Name): PROJECT RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9760 BIRCH CANYON PL
SAN DIEGO CA
92126-1076
US

IV. Provider business mailing address

2411 FENTON ST STE 103
CHULA VISTA CA
91914-3517
US

V. Phone/Fax

Practice location:
  • Phone: 760-581-4357
  • Fax:
Mailing address:
  • Phone: 760-581-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLES JACKSON
Title or Position: CCO
Credential:
Phone: 480-787-1591