MEDICARE: RECOVERY BAY REHABILITATION CENTER, 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	300300AP	CA

General Provider Information

NPI Number	:	1508240268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECOVERY BAY REHABILITATION CENTER, LLC

Provider Business Mailing Address
First Line	:	8 CHESHIRE CT
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-4210
Country	:	US
Telephone Number	:	949-289-0350
Fax Number	:

Provider Business Practice Location Address
First Line	:	18912 PATRICIAN DR
Second Line	:
City	:	VILLA PARK
State	:	CA
Zip	:	92861-4214
Country	:	US
Telephone Number	:	949-887-6379
Fax Number	:

Authorized Official
Title or Position	:	CEO/EXECUTIVE DIRECTOR
Name	:	MS. IZZY HIRSON
Credential	:
Telephone Number	:	949-887-6379

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	07/13/2015

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