=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871131078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY RECOVERY INTENSIVE OUTPATIENT PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2019
-----------------------------------------------------
Last Update Date | 12/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 W TOWN AND COUNTRY RD STE 1208
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-225-5994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9592 PERIDOT AVE
-----------------------------------------------------
City | HESPERIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92344-8099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-225-5994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OF OPERATIONS
-----------------------------------------------------
Name | JAMAN ELEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-225-5994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------