=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245744689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE RECOVERY PAD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2017
-----------------------------------------------------
Last Update Date | 11/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31877 DEL OBISPO ST STE 209
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-388-0224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31562 VIA DULCINEA
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-388-0224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DONNA QUINN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-388-0224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------