=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700626629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADDICTION SPECIALIST OF SOUTHERN CALIFORNIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2024
-----------------------------------------------------
Last Update Date | 05/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 MACARTHUR BLVD SUITE 600 EAST TOWER
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-390-4730
-----------------------------------------------------
Fax | 949-627-8107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 ENGLISH SADDLE
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92602-1839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-390-4730
-----------------------------------------------------
Fax | 949-627-8107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LAWRENCE VERNON TUCKER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-390-4730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------