=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164466785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGUNA BEACH REHAB, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 10/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 AVOCADO AVE STE 307
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-640-2121
-----------------------------------------------------
Fax | 949-640-2631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1441 AVOCADO AVE STE 307
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-640-2121
-----------------------------------------------------
Fax | 949-640-2631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | H.R. MANAGER
-----------------------------------------------------
Name | MR. BRIAN R FRACALOSY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-640-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | BT00015281
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------