MEDICARE: SEA CHANGE SANTA MONICA, LP

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	190831AP	CA

General Provider Information

NPI Number	:	1063899524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEA CHANGE SANTA MONICA, LP

Provider Business Mailing Address
First Line	:	212 26TH ST
Second Line	:	# 102
City	:	SANTA MONICA
State	:	CA
Zip	:	90402-2524
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1831 WILSHIRE BLVD
Second Line	:	C
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5777
Country	:	US
Telephone Number	:	310-877-6030
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CAROLE ANDRESS
Credential	:
Telephone Number	:	310-877-6030

Provider Enumeration Date	:	05/04/2015
Last Update Date	:	01/19/2021

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