Healthcare Provider Details

I. General information

NPI: 1467720243
Provider Name (Legal Business Name): POSITIVE RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17291 IRVINE BLVD STE 104
TUSTIN CA
92780-2929
US

IV. Provider business mailing address

17291 IRVINE BLVD STE 104
TUSTIN CA
92780-2929
US

V. Phone/Fax

Practice location:
  • Phone: 714-730-0505
  • Fax: 714-730-0113
Mailing address:
  • Phone: 714-730-0505
  • Fax: 714-730-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPSY6949
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberPSY6949
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY6949
License Number StateCA

VIII. Authorized Official

Name: MISS ANA M CORDOVA
Title or Position: MANAGER
Credential:
Phone: 714-730-0505