Provider Demographics
NPI:1215582234
Name:SO CAL RECOVERY CENTERS DP LLC
Entity Type:Organization
Organization Name:SO CAL RECOVERY CENTERS DP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-481-6156
Mailing Address - Street 1:34249 CAMINO CAPISTRANO STE 101
Mailing Address - Street 2:
Mailing Address - City:CAPISTRANO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92624-1156
Mailing Address - Country:US
Mailing Address - Phone:949-481-6156
Mailing Address - Fax:949-542-3878
Practice Address - Street 1:44267 MONTEREY AVE STE A&B
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2755
Practice Address - Country:US
Practice Address - Phone:949-481-6156
Practice Address - Fax:949-542-3878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-06
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
05D2152160OtherCLIA
CA330018APOtherSTATE OF CALIFORNIA