MEDICARE: HOWER LODGE, INC.

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1679335483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOWER LODGE, INC.

Provider Business Mailing Address
First Line	:	33171 PASEO CERVEZA
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-4824
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 NEWPORT BLVD
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-3714
Country	:	US
Telephone Number	:	949-701-1959
Fax Number	:

Authorized Official
Title or Position	:	CCO/MANAGING MEMBER
Name	:	PETER GATES
Credential	:
Telephone Number	:	949-701-1959

Provider Enumeration Date	:	01/26/2024
Last Update Date	:	01/26/2024

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Directions to “HOWER LODGE, INC. ” Practice Location

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