Basic Information
| Provider Information | |||||||||
| NPI: | 1588831432 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MALIBU BEACH RECOVERY CENTER, LLC | ||||||||
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| OtherOrganizationName: | MALIBU BEACH RECOVERY CENTER - CORRAL CANYON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 WINDY RIDGE PARKWAY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4704401647 | ||||||||
| FaxNumber: | 6788130505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1752 CORRAL CANYON RD | ||||||||
| Address2: | |||||||||
| City: | MALIBU | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902652906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104562026 | ||||||||
| FaxNumber: | 3104566528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 07/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | TOWNSEND | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 4704401647 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERMEND HEALTH, LLC | ||||||||
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| AuthorizedOfficialCredential: | MPH, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190562AP | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.