Provider Demographics
NPI:1003435033
Name:RESURGENCE CALIFORNIA, LLC
Entity Type:Organization
Organization Name:RESURGENCE CALIFORNIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORRECA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-700-5053
Mailing Address - Street 1:3151 AIRWAY AVE STE E1
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:158 MARION BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3525
Practice Address - Country:US
Practice Address - Phone:949-899-6003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300045FPOtherCA DHCS