MEDICARE: RECOVERY CAFE SANTA CRUZ

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1700650579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECOVERY CAFE SANTA CRUZ

Provider Business Mailing Address
First Line	:	PO BOX 7841
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95061-7841
Country	:	US
Telephone Number	:	831-222-0554
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 FRONT STREET #7841
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95061
Country	:	US
Telephone Number	:	831-687-8783
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	SERG KAGNO
Credential	:
Telephone Number	:	831-222-0554

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	11/20/2023

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