Provider Demographics
NPI:1497414379
Name:CRESCENT MOON RECOVERY, LLC
Entity Type:Organization
Organization Name:CRESCENT MOON RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-706-8898
Mailing Address - Street 1:18652 FLORIDA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6000
Mailing Address - Country:US
Mailing Address - Phone:714-464-8474
Mailing Address - Fax:714-948-8883
Practice Address - Street 1:18652 FLORIDA ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6000
Practice Address - Country:US
Practice Address - Phone:714-464-8474
Practice Address - Fax:714-948-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACLR-90002425OtherCDPH CLIA LICENSE, STATE ID
CA300398APOtherCALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES, OUTPATIENT CERTIFICATION
661764OtherTHE JOINT COMMISSION
05D2207074OtherCLINICAL AND PUBLIC HEALTH LABORATORY LICENSE, CLIA ID