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General NPI Number Information
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NPI Number | 1568024263
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Entity Type | Organization
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Legal Business Name | INTEGRATED RECOVERY FOUNDATION 22
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Dates
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Enumeration Date | 07/02/2019
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Last Update Date | 06/09/2020
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Provider Practice Location Address
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Address Line | 30211 AVENIDA DE LAS BANDERA STE 200
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City | RANCHO SANTA MARGARITA
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State | CA
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Zip | 92688-2159
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Country | US
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Telephone | 949-533-6075
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Fax | 949-484-7021
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Provider Business Mailing Address
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Address Line | 25 FLOR AMOR
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City | RANCHO SANTA MARGARITA
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State | CA
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Zip | 92688
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Country | US
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Telephone | 951-813-1720
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Fax | 949-484-7021
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Authorized Official
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Title or Position | UR/BILLING
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Name | MYRNA B FERNANDEZ
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Credential | LPT
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Telephone | 951-813-1720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number |
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License Number State |
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