Healthcare Provider Details

I. General information

NPI: 1730883224
Provider Name (Legal Business Name): SEA CHANGE RECOVERY 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 WILSHIRE BLVD STE CANDC2
SANTA MONICA CA
90403-5777
US

IV. Provider business mailing address

2973 HARBOR BLVD STE 140
COSTA MESA CA
92626-3912
US

V. Phone/Fax

Practice location:
  • Phone: 949-244-5481
  • Fax:
Mailing address:
  • Phone: 949-244-5481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANGELA MCMAHON
Title or Position: COMPLIANCE
Credential:
Phone: 619-871-7345