Basic Information
| Provider Information | |||||||||
| NPI: | 1194735829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WCHS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERSIDE TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6183 PASEO DEL NORTE, STE 200 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552592288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1021 W LA CADENA DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925011413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517848010 | ||||||||
| FaxNumber: | 9517842859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 3390 | 05 | CA | MEDICAID |