Basic Information
Provider Information | |||||||||
NPI: | 1407084304 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CRC HEALTH GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TEMECULA VALLEY TREATMENT CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40700 CALIFORNIA OAKS RD | ||||||||
Address2: |   | ||||||||
City: | MURRIETA | ||||||||
State: | CA | ||||||||
PostalCode: | 925625789 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9518945072 | ||||||||
FaxNumber: | 9518947324 | ||||||||
Practice Location | |||||||||
Address1: | 40700 CALIFORNIA OAKS RD | ||||||||
Address2: |   | ||||||||
City: | MURRIETA | ||||||||
State: | CA | ||||||||
PostalCode: | 925625789 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9518945072 | ||||||||
FaxNumber: | 9518947324 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2009 | ||||||||
LastUpdateDate: | 06/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NGUYEN | ||||||||
AuthorizedOfficialFirstName: | HIEU | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9518945072 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.A | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | VN240706 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.