Provider Demographics
NPI:1467836122
Name:WEST COAST RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:WEST COAST RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-266-7682
Mailing Address - Street 1:25190 HANCOCK AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5947
Mailing Address - Country:US
Mailing Address - Phone:951-223-4786
Mailing Address - Fax:951-929-2780
Practice Address - Street 1:25190 HANCOCK AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5947
Practice Address - Country:US
Practice Address - Phone:951-223-4786
Practice Address - Fax:951-929-2780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330130AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility