Provider Demographics
NPI:1265680953
Name:LAGUNA BEACH RECOVERY
Entity Type:Organization
Organization Name:LAGUNA BEACH RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:KISNER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, CADC-II
Authorized Official - Phone:714-913-0852
Mailing Address - Street 1:316 THALIA ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2714
Mailing Address - Country:US
Mailing Address - Phone:866-493-4527
Mailing Address - Fax:949-497-3687
Practice Address - Street 1:316 THALIA ST
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2714
Practice Address - Country:US
Practice Address - Phone:866-493-4527
Practice Address - Fax:949-497-3687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300197AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300197APOtherLICENSE/CERTIFICATION DRUG AND ALCOHOL