=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174038939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANCHES RECOVERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2017
-----------------------------------------------------
Last Update Date | 12/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19905 BEDFORD CANYON RD
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92881-4827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-317-5571
-----------------------------------------------------
Fax | 951-444-7818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2279 EAGLE GLEN PKWY # 112-409
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92883-0790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-317-5571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. CELESTE PAFFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-317-5571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------