=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851802458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDRA ROSE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35402 CAMINO CAPISTRANO
-----------------------------------------------------
City | DANA POINT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92624-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-584-5927
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4009 CALLE ABRIL
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-584-5927
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SALINA SHULER
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 714-785-2512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 300245AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------