Provider Demographics
NPI:1114006830
Name:CHILDREN'S RECOVERY CENTER 1, LLC
Entity Type:Organization
Organization Name:CHILDREN'S RECOVERY CENTER 1, LLC
Other - Org Name:CHILDREN'S RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-340-1568
Mailing Address - Street 1:3777 S. BASCOM AVE.
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008
Mailing Address - Country:US
Mailing Address - Phone:408-340-1568
Mailing Address - Fax:408-866-8144
Practice Address - Street 1:3777 S. BASCOM AVE.
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008
Practice Address - Country:US
Practice Address - Phone:408-340-1568
Practice Address - Fax:408-866-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000320282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC40007FMedicare ID - Type UnspecifiedMEDICARE LTC NUMBER