Provider Demographics
NPI:1316402225
Name:CREST RECOVERY LLC
Entity Type:Organization
Organization Name:CREST RECOVERY LLC
Other - Org Name:TRUVIDA RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CEAIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:833-233-0091
Mailing Address - Street 1:23726 BIRTCHER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1771
Mailing Address - Country:US
Mailing Address - Phone:949-283-4679
Mailing Address - Fax:
Practice Address - Street 1:26886 PUEBLONUEVO DR
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-4410
Practice Address - Country:US
Practice Address - Phone:949-283-4679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300351EPOtherDHCS