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General NPI Number Information
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NPI Number | 1164511465
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Entity Type | Organization
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Legal Business Name | PROVIDENCE RECOVERY CENTER, INC.
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 05/18/2010
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Provider Practice Location Address
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Address Line | 831 PAGET AVE
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City | SANTA CRUZ
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State | CA
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Zip | 95062-4112
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Country | US
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Telephone | 831-475-1326
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Fax | 831-475-7881
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Provider Business Mailing Address
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Address Line | PO BOX 701
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City | CAPITOLA
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State | CA
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Zip | 95010-0701
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Country | US
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Telephone | 831-475-1326
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Fax | 831-475-7881
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. CLAUDIA JANE PORTER
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Credential | CAC
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Telephone | 831-475-1326
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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 | 440013AP
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License Number State | CA
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