Healthcare Provider Details

I. General information

NPI: 1629552542
Provider Name (Legal Business Name): NAUTILUS RECOVERY GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/06/2023
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5803 CORBIN AVE
TARZANA CA
91356-1004
US

IV. Provider business mailing address

8033 W SUNSET BLVD # 946
WEST HOLLYWOOD CA
90046-2401
US

V. Phone/Fax

Practice location:
  • Phone: 734-751-4956
  • Fax:
Mailing address:
  • Phone: 310-795-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JASON VAUGHN SHOEMAKER
Title or Position: CEO
Credential: PHD
Phone: 310-795-4066