=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255750519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOCAL DETOX, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 04/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1703 AVENIDA SALVADOR
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-3268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-584-5957
-----------------------------------------------------
Fax | 360-323-7285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1703 AVENIDA SALVADOR
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-3268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-584-5957
-----------------------------------------------------
Fax | 360-323-7285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOSHUA LAWRENCE BEAUCHAINE
-----------------------------------------------------
Credential | LMFT 47103
-----------------------------------------------------
Telephone | 949-584-5957
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | TBD
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------