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General NPI Number Information
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NPI Number | 1710365598
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Entity Type | Organization
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Legal Business Name | BEACHSIDE RECOVERY, LLC
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Dates
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Enumeration Date | 05/12/2015
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Last Update Date | 12/10/2018
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Provider Practice Location Address
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Address Line | 16490 HARBOR BLVD. A-B
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708
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Country | US
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Telephone | 949-393-4070
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 511330
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City | LOS ANGELES
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State | CA
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Zip | 90051-7885
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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 | SUPERVISOR
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Name | DARRYLE LEE MACKELVEY
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Credential |
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Telephone | 714-948-6086
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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 | 300315BP
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License Number State | CA
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