Basic Information
| Provider Information | |||||||||
| NPI: | 1710160833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL RECOVERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19109 GALWAY AVE | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907461915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103296548 | ||||||||
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| Practice Location | |||||||||
| Address1: | 117 E HARRY BRIDGES BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907445825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105498383 | ||||||||
| FaxNumber: | 3105499304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3105498383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 230562 | CA | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.