Provider Demographics
NPI:1508130808
Name:NEW LIFE SPIRIT RECOVERY, INC.
Entity Type:Organization
Organization Name:NEW LIFE SPIRIT RECOVERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MCA, MRAS, MDAAC
Authorized Official - Phone:714-841-1906
Mailing Address - Street 1:18652 FLORIDA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1924
Mailing Address - Country:US
Mailing Address - Phone:714-841-1906
Mailing Address - Fax:714-908-3308
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:92648-1924
Practice Address - Country:US
Practice Address - Phone:714-841-1906
Practice Address - Fax:714-908-3308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-04
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300190AP261QR0401X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300190APOtherDHCS - DEPARTMENT OF HEALTH CARE SERVICES