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General NPI Number Information
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NPI Number | 1467817114
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Entity Type | Organization
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Legal Business Name | SOUTH SHORES DETOX LLC
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Dates
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Enumeration Date | 12/23/2015
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Last Update Date | 09/09/2016
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Provider Practice Location Address
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Address Line | 32851 BUCCANEER ST
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City | DANA POINT
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State | CA
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Zip | 92629-1312
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Country | US
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Telephone | 949-289-2138
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Fax |
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Provider Business Mailing Address
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Address Line | 31746 VIA BELARDES
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City | SAN JUAN CAPISTRANO
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State | CA
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Zip | 92675-3031
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Country | US
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Telephone | 949-289-2138
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | MR. JOSH D SMITH
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Credential |
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Telephone | 949-289-2138
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 300324AP
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 300352AP
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License Number State | CA
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