=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700361615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINGS RECOVERY CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2018
-----------------------------------------------------
Last Update Date | 09/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1013 CREST VIEW RD
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92081-6806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-220-9519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 785 GRAND AVE STE 101
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-2370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-220-9519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | KATY HOSLAR
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 858-220-9519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------