Provider Demographics
NPI:1578911624
Name:WILLOW SPRINGS RECOVERY
Entity Type:Organization
Organization Name:WILLOW SPRINGS RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-835-4359
Mailing Address - Street 1:30950 RANCHO VIEJO RD STE 225
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1772
Mailing Address - Country:US
Mailing Address - Phone:949-835-4359
Mailing Address - Fax:949-429-1845
Practice Address - Street 1:1128 HIGHWAY 21 E
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-5884
Practice Address - Country:US
Practice Address - Phone:949-835-4359
Practice Address - Fax:949-429-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
TX4103-4104324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility