Provider Demographics
NPI:1467720243
Name:POSITIVE RECOVERY CENTER
Entity Type:Organization
Organization Name:POSITIVE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-730-0505
Mailing Address - Street 1:17291 IRVINE BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2929
Mailing Address - Country:US
Mailing Address - Phone:714-730-0505
Mailing Address - Fax:714-730-0113
Practice Address - Street 1:17291 IRVINE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2929
Practice Address - Country:US
Practice Address - Phone:714-730-0505
Practice Address - Fax:714-730-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6949103T00000X, 103TH0100X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY6949OtherBLUE CROSS/BLUE SHIELD PPO
CAPSY6949OtherPRIVATE
CAPSY6949OtherWORKERS COMPENSATION