Provider Demographics
NPI:1598392417
Name:DANA POINT DETOX LLC
Entity Type:Organization
Organization Name:DANA POINT DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IZZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-359-5662
Mailing Address - Street 1:24832 LA PAZ AVE APT B
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-5398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24832 LA PAZ AVE APT B
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-5398
Practice Address - Country:US
Practice Address - Phone:949-359-5662
Practice Address - Fax:949-542-3878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-23
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300392APOtherSTATE OF CA
05D2183497OtherCLIA