Provider Demographics
NPI:1164511465
Name:PROVIDENCE RECOVERY CENTER, INC.
Entity Type:Organization
Organization Name:PROVIDENCE RECOVERY CENTER, INC.
Other - Org Name:PROVIDENCE RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:CAC
Authorized Official - Phone:831-475-1326
Mailing Address - Street 1:PO BOX 701
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-0701
Mailing Address - Country:US
Mailing Address - Phone:831-475-1326
Mailing Address - Fax:831-475-7881
Practice Address - Street 1:831 PAGET AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4112
Practice Address - Country:US
Practice Address - Phone:831-475-1326
Practice Address - Fax:831-475-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA440013AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility