=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265680953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGUNA BEACH RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2008
-----------------------------------------------------
Last Update Date | 09/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 THALIA ST
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92651-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-493-4527
-----------------------------------------------------
Fax | 949-497-3687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 THALIA ST
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92651-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-493-4527
-----------------------------------------------------
Fax | 949-497-3687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. MARK RONALD KISNER
-----------------------------------------------------
Credential | MSW, CADC-II
-----------------------------------------------------
Telephone | 714-913-0852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 300197AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------