=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770284960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILLSIDE RECOVERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2023
-----------------------------------------------------
Last Update Date | 03/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1148 VIA ARROYO
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-1317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-415-2441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 DUVALI DR
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-415-2441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KERRY HOFFMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-415-2441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------