Provider Demographics
NPI:1467217372
Name:PSYCHOGENESIS DETOX CENTER
Entity Type:Organization
Organization Name:PSYCHOGENESIS DETOX CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NADER
Authorized Official - Middle Name:
Authorized Official - Last Name:BABAI SIAHDOHONI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-769-1372
Mailing Address - Street 1:30912 STEEPLECHASE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1928
Mailing Address - Country:US
Mailing Address - Phone:949-769-1372
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE STE C3
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4622
Practice Address - Country:US
Practice Address - Phone:949-769-1372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INSPIRE HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder