Provider Demographics
NPI:1023566445
Name:HEALING WATERS RECOVERY, LLC EASTVALE
Entity Type:Organization
Organization Name:HEALING WATERS RECOVERY, LLC EASTVALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-233-0677
Mailing Address - Street 1:19069 VAN BUREN BLVD
Mailing Address - Street 2:114 116
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508
Mailing Address - Country:US
Mailing Address - Phone:772-233-0677
Mailing Address - Fax:
Practice Address - Street 1:13757 ASPEN LEAF LANE
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880
Practice Address - Country:US
Practice Address - Phone:772-233-0677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALING WATERS RECOVERY ASP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201617610555324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility