MEDICARE: SCRC DANA POINT 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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1437872645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCRC DANA POINT LLC

Provider Business Mailing Address
First Line	:	34249 CAMINO CAPISTRANO # 101
Second Line	:
City	:	CAPO BEACH
State	:	CA
Zip	:	92624-1156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34249 CAMINO CAPISTRANO # 201
Second Line	:
City	:	CAPO BEACH
State	:	CA
Zip	:	92624-1156
Country	:	US
Telephone Number	:	949-359-5669
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MATTHEW LEE
Credential	:
Telephone Number	:	619-987-8078

Provider Enumeration Date	:	09/22/2022
Last Update Date	:	09/22/2022

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Directions to “SCRC DANA POINT LLC ” Practice Location

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