Provider Demographics
NPI:1164466785
Name:LAGUNA BEACH REHAB, INC.
Entity Type:Organization
Organization Name:LAGUNA BEACH REHAB, INC.
Other - Org Name:CORONA DEL MAR REHAB, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:H.R. MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FRACALOSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-640-2121
Mailing Address - Street 1:1441 AVOCADO AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7704
Mailing Address - Country:US
Mailing Address - Phone:949-640-2121
Mailing Address - Fax:949-640-2631
Practice Address - Street 1:1441 AVOCADO AVE STE 307
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7704
Practice Address - Country:US
Practice Address - Phone:949-640-2121
Practice Address - Fax:949-640-2631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABT00015281261Q00000X
261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19811OtherMEDICARE, PTAN