Basic Information
| Provider Information | |||||||||
| NPI: | 1295820835 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TWIN TOWN CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TWIN TOWN TREATMENT CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4281 KATELLA AVE STE 211 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907206500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625948844 | ||||||||
| FaxNumber: | 5624931280 | ||||||||
| Practice Location | |||||||||
| Address1: | 4281 KATELLA AVE STE 117 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907203590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625960050 | ||||||||
| FaxNumber: | 5625960058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LISONBEE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ CEO | ||||||||
| AuthorizedOfficialTelephone: | 3106299669 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TWIN TOWN CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 300128 & 190290 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.