Provider Demographics
NPI:1295223147
Name:PACIFIC LIGHT RECOVERY CENTER
Entity Type:Organization
Organization Name:PACIFIC LIGHT RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-250-9323
Mailing Address - Street 1:304 ARCADIA CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2296
Mailing Address - Country:US
Mailing Address - Phone:917-250-9323
Mailing Address - Fax:
Practice Address - Street 1:811 CHURCH RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-1412
Practice Address - Country:US
Practice Address - Phone:917-250-9323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder