Provider Demographics
NPI:1417307125
Name:WATERFRONT RECOVERY SERVICES
Entity Type:Organization
Organization Name:WATERFRONT RECOVERY SERVICES
Other - Org Name:WATERFRONT RECOVERY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:MCMANUS
Authorized Official - Suffix:
Authorized Official - Credentials:CATC
Authorized Official - Phone:707-445-1391
Mailing Address - Street 1:2109 BROADWAY STE A
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-2106
Mailing Address - Country:US
Mailing Address - Phone:707-445-1391
Mailing Address - Fax:707-445-2599
Practice Address - Street 1:2413 2ND ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0811
Practice Address - Country:US
Practice Address - Phone:707-269-9590
Practice Address - Fax:707-445-2599
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALCOHOL DRUG CARE SERVICES,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-14
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120009AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility