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General NPI Number Information
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NPI Number | 1568830081
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Entity Type | Organization
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Legal Business Name | FIRST LIGHT RECOVERY
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Dates
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Enumeration Date | 09/15/2015
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Last Update Date | 09/15/2015
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Provider Practice Location Address
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Address Line | 140 AVENIDA ALGODON
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City | SAN CLEMENTE
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State | CA
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Zip | 92627
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Country | US
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Telephone | 949-294-5104
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Fax |
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Provider Business Mailing Address
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Address Line | 140 AVENIDA ALGODON
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-4182
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MELODY JOY STONE
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Credential | LMFT
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Telephone | 949-294-5104
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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 | 300325AP
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License Number State | CA
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