Provider Demographics
NPI:1235661315
Name:EXPERIENCE RECOVERY IOP
Entity Type:Organization
Organization Name:EXPERIENCE RECOVERY IOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PREMAZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-865-1052
Mailing Address - Street 1:3919 W HAZARD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-2625
Mailing Address - Country:US
Mailing Address - Phone:714-865-1052
Mailing Address - Fax:
Practice Address - Street 1:5405 GARDEN GROVE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-1887
Practice Address - Country:US
Practice Address - Phone:714-713-5272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health