Provider Demographics
NPI:1164873253
Name:IRECOVERY BEHAVIORAL HEALTH CLINIC, LLC
Entity Type:Organization
Organization Name:IRECOVERY BEHAVIORAL HEALTH CLINIC, LLC
Other - Org Name:IRECOVERY SANTA MARIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-631-5268
Mailing Address - Street 1:68778 E PALM CANYON DR
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-1313
Mailing Address - Country:US
Mailing Address - Phone:805-631-5268
Mailing Address - Fax:805-631-5264
Practice Address - Street 1:607 PLAZA DR
Practice Address - Street 2:SUITE C-102
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6944
Practice Address - Country:US
Practice Address - Phone:805-631-5268
Practice Address - Fax:805-631-5264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder