Provider Demographics
NPI:1467968677
Name:LIFE VESSEL TREATMENT AND RECOVERY
Entity Type:Organization
Organization Name:LIFE VESSEL TREATMENT AND RECOVERY
Other - Org Name:THE MISSION HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:B
Authorized Official - Last Name:CABRERA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:949-388-4114
Mailing Address - Street 1:1040 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-4503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25466 GLORIOSA DR
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-4642
Practice Address - Country:US
Practice Address - Phone:949-388-4114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300683AP276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit