MEDICARE: WEST COAST DETOX, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	300228AP	CA

General Provider Information

NPI Number	:	1063700433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST DETOX, INC.

Provider Business Mailing Address
First Line	:	6381 YALE CIR
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-2557
Country	:	US
Telephone Number	:	866-448-2723
Fax Number	:	866-703-9903

Provider Business Practice Location Address
First Line	:	6381 YALE CIR
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-2557
Country	:	US
Telephone Number	:	866-448-2723
Fax Number	:	866-703-9903

Authorized Official
Title or Position	:	INSURANCE COORDINATOR
Name	:	REINER NUSBAUM
Credential	:
Telephone Number	:	949-235-8258

Provider Enumeration Date	:	07/19/2011
Last Update Date	:	07/19/2011

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