Provider Demographics
NPI:1558554915
Name:PACIFIC VALLEY RECOVERY CENTER INCORPORATED
Entity Type:Organization
Organization Name:PACIFIC VALLEY RECOVERY CENTER INCORPORATED
Other - Org Name:N/A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/DIRECTOR OF PROGRAMS
Authorized Official - Prefix:
Authorized Official - First Name:CHARLSIE
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-817-5720
Mailing Address - Street 1:2491 BURLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4029
Mailing Address - Country:US
Mailing Address - Phone:209-817-5720
Mailing Address - Fax:
Practice Address - Street 1:820 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-3129
Practice Address - Country:US
Practice Address - Phone:209-817-5720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390030AN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder