Provider Demographics
NPI:1396211900
Name:IMAGINE RECOVERY GROUP
Entity Type:Organization
Organization Name:IMAGINE RECOVERY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:YBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-312-0165
Mailing Address - Street 1:1247 N LAKEVIEW AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-1833
Mailing Address - Country:US
Mailing Address - Phone:714-312-0165
Mailing Address - Fax:714-970-9779
Practice Address - Street 1:1247 N LAKEVIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-1833
Practice Address - Country:US
Practice Address - Phone:714-312-0165
Practice Address - Fax:714-970-9779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility