MEDICARE: FULL CIRCLE RECOVERY

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	330141AN	OTHER	CA	DHCS

General Provider Information

NPI Number	:	1306498431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL CIRCLE RECOVERY

Provider Business Mailing Address
First Line	:	1860 LAMPTON LN
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-3614
Country	:	US
Telephone Number	:	951-737-6199
Fax Number	:	877-963-6329

Provider Business Practice Location Address
First Line	:	765 GARDEN GROVE AVE
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-2355
Country	:	US
Telephone Number	:	951-737-6199
Fax Number	:	877-963-6329

Authorized Official
Title or Position	:	COO
Name	:	SAMANTHA DOTY
Credential	:
Telephone Number	:	951-737-6199

Provider Enumeration Date	:	07/09/2019
Last Update Date	:	07/09/2019

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Directions to “FULL CIRCLE RECOVERY ” Practice Location

Language	Start Address	Practice Location

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