Basic Information
| Provider Information | |||||||||
| NPI: | 1407282247 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TWIN TOWN CORPORATION | ||||||||
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| OtherOrganizationName: | TWIN TOWN TREATMENT CENTERS, ORANGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4388 KATELLA AVE. | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665948844 | ||||||||
| FaxNumber: | 5624931280 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 WEST LA VETA STE. 208 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145329295 | ||||||||
| FaxNumber: | 5624931280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | LISONBEE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3106299669 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TWIN TOWN | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 300128CP | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.