Basic Information
Provider Information | |||||||||
NPI: | 1881020626 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TWIN TOWN CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TWIN TOWN TREATMENT CENTERS, MISSION VIEJO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4388 KATELLA AVE. | ||||||||
Address2: |   | ||||||||
City: | LOS ALAMITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 90720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8665948844 | ||||||||
FaxNumber: | 5624931280 | ||||||||
Practice Location | |||||||||
Address1: | 24953 PASEO DE VALENCIA BLDG B SUITE 1B | ||||||||
Address2: |   | ||||||||
City: | LAGUNA HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 926534342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9495400170 | ||||||||
FaxNumber: | 9495400173 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2013 | ||||||||
LastUpdateDate: | 08/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LISONBEE | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | PAUL | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/ PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3106299669 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TWIN TOWN | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 300128DP | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.