MEDICARE: CANYON CREST RECOVERY LLC

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

General Provider Information

NPI Number	:	1366237778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON CREST RECOVERY LLC

Provider Business Mailing Address
First Line	:	11530 VENEZIA WAY
Second Line	:
City	:	PORTER RANCH
State	:	CA
Zip	:	91326-4404
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19238 ARMINTA ST
Second Line	:
City	:	RESEDA
State	:	CA
Zip	:	91335-1107
Country	:	US
Telephone Number	:	781-964-2691
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TIMOTHY MEISE
Credential	:
Telephone Number	:	609-342-9430

Provider Enumeration Date	:	04/14/2025
Last Update Date	:	04/14/2025

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Directions to “CANYON CREST RECOVERY LLC ” Practice Location

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