=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164888442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILESTONE DETOX, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2016
-----------------------------------------------------
Last Update Date | 01/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31981 CALLE WINONA
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-3076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-344-8149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1040 W 17TH ST
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-388-4114
-----------------------------------------------------
Fax | 949-203-8540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. SHAWN WHITT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-344-8149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------