Provider Demographics
NPI:1598370710
Name:MIRA COAST BEHAVIORAL
Entity Type:Organization
Organization Name:MIRA COAST BEHAVIORAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:INDIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-335-8802
Mailing Address - Street 1:326 OLD NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:754-212-0473
Practice Address - Street 1:326 OLD NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4121
Practice Address - Country:US
Practice Address - Phone:949-335-8802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health