=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205209749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADOLESCENT ACADEMY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2015
-----------------------------------------------------
Last Update Date | 11/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29970 TECHNOLOGY DR STE 117G
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-2647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-698-7612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1033
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92564-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-698-7612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | MR. FARHAN QURESHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-698-7612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------