Provider Demographics
NPI:1164888442
Name:MILESTONE DETOX, LLC
Entity Type:Organization
Organization Name:MILESTONE DETOX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-344-8149
Mailing Address - Street 1:1040 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-4503
Mailing Address - Country:US
Mailing Address - Phone:949-388-4114
Mailing Address - Fax:949-203-8540
Practice Address - Street 1:31981 CALLE WINONA
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3076
Practice Address - Country:US
Practice Address - Phone:949-344-8149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-03
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder