Provider Demographics
NPI:1497415137
Name:CRESCENT MOON RECOVERY- ORANGE COUNTY IOP, LLC
Entity Type:Organization
Organization Name:CRESCENT MOON RECOVERY- ORANGE COUNTY IOP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-761-9659
Mailing Address - Street 1:308 22ND ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-3308
Mailing Address - Country:US
Mailing Address - Phone:714-242-5099
Mailing Address - Fax:
Practice Address - Street 1:308 22ND ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-3308
Practice Address - Country:US
Practice Address - Phone:714-242-5099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness