Basic Information
| Provider Information | |||||||||
| NPI: | 1558614396 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRC HEALTH GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RECOVERY SOLUTIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 EAST 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145423581 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2101 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927054007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145423581 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PADILLA | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | ARTHUR | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 9514436081 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CRC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RRW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.