Provider Demographics
NPI:1124419379
Name:I CHOOSE LIFE ADDICTION SPECIALIST
Entity Type:Organization
Organization Name:I CHOOSE LIFE ADDICTION SPECIALIST
Other - Org Name:ICLASS TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RENALDO
Authorized Official - Middle Name:ROLANDO
Authorized Official - Last Name:MOODIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MFT
Authorized Official - Phone:951-339-8443
Mailing Address - Street 1:3380 LA SIERRA AVE
Mailing Address - Street 2:SUITE 104-730
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5271
Mailing Address - Country:US
Mailing Address - Phone:951-339-8443
Mailing Address - Fax:951-339-8443
Practice Address - Street 1:425 E 6TH ST
Practice Address - Street 2:UNIT 201
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1566
Practice Address - Country:US
Practice Address - Phone:951-339-8443
Practice Address - Fax:951-339-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)