Healthcare Provider Details

I. General information

NPI: 1689156507
Provider Name (Legal Business Name): LEAD RECOVERY TRANSITIONAL LIVING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 BROOKHOLLOW DR UNIT A
SANTA ANA CA
92705-5401
US

IV. Provider business mailing address

1516 BROOKHOLLOW DR UNIT A
SANTA ANA CA
92705-5401
US

V. Phone/Fax

Practice location:
  • Phone: 949-282-9447
  • Fax: 949-666-8393
Mailing address:
  • Phone: 949-282-9447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN NURMBERG
Title or Position: CFO
Credential:
Phone: 949-282-9447