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General NPI Number Information
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NPI Number | 1013459569
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Entity Type | Organization
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Legal Business Name | COASTAL RECOVERY, INC.
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Dates
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Enumeration Date | 11/15/2016
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Last Update Date | 12/22/2016
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Provider Practice Location Address
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Address Line | 11851 WISTERIA AVE
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-2654
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Country | US
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Telephone | 949-642-4150
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Fax | 949-642-3441
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Provider Business Mailing Address
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Address Line | 11851 WISTERIA AVE
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-2654
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Country | US
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Telephone | 949-642-4150
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Fax | 949-642-3441
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MARSHALL ANTHONY EDDY
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Credential |
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Telephone | 949-413-1390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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