Provider Demographics
NPI:1417317421
Name:NATIONWIDE RECOVERY CENTERS, LLC
Entity Type:Organization
Organization Name:NATIONWIDE RECOVERY CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-260-8577
Mailing Address - Street 1:555 N EL CAMINO REAL
Mailing Address - Street 2:STE A141
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-6740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22602 COSTA BELLA DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4218
Practice Address - Country:US
Practice Address - Phone:203-260-8577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300634AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility