=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306388038
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PILLARS RECOVERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2016
-----------------------------------------------------
Last Update Date | 11/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 326 OLD NEWPORT BLVD
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-4121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-548-1500
-----------------------------------------------------
Fax | 949-608-0116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 986
-----------------------------------------------------
City | CORONA DEL MAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92625-5986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-548-1500
-----------------------------------------------------
Fax | 949-608-0116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | PETER M GATES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-548-1500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 300312CP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------