=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104257369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRED BROWN'S RECOVERY SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2013
-----------------------------------------------------
Last Update Date | 03/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 270 W 14TH ST # 3
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-519-8723
-----------------------------------------------------
Fax | 310-519-9428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2743
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-0182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-519-8723
-----------------------------------------------------
Fax | 310-519-9428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. ROXANNA NATALE-BROWN
-----------------------------------------------------
Credential | LAADCNR, CADCII, SAP
-----------------------------------------------------
Telephone | 310-519-8723
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 190135MN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------