Healthcare Provider Details

I. General information

NPI: 1306354634
Provider Name (Legal Business Name): SEA CHANGE SANTA MONICA, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 PIER AVE
SANTA MONICA CA
90405-5947
US

IV. Provider business mailing address

1831 WILSHIRE BLVD STE C
SANTA MONICA CA
90403-5778
US

V. Phone/Fax

Practice location:
  • Phone: 888-823-3310
  • Fax: 323-843-9800
Mailing address:
  • Phone: 424-330-0396
  • Fax: 323-843-9800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number190831AP
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190831BP
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190831CP
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ALEXXIS KYLA AMES
Title or Position: INSURANCE MANAGER
Credential:
Phone: 424-330-0396