Provider Demographics
NPI:1306217500
Name:COASTLINE RECOVERY LLC
Entity Type:Organization
Organization Name:COASTLINE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-345-5577
Mailing Address - Street 1:18377 BEACH BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1349
Mailing Address - Country:US
Mailing Address - Phone:949-205-1065
Mailing Address - Fax:714-388-3844
Practice Address - Street 1:18377 BEACH BLVD STE 210
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1349
Practice Address - Country:US
Practice Address - Phone:949-205-1065
Practice Address - Fax:714-388-3844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300630BP261QM0850X, 261QR0405X
CA1445363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300630BPOtherDHCS CERTIFICATION
608177OtherTHE JOINT COMMISSION