Provider Demographics
NPI:1629552542
Name:NAUTILUS RECOVERY GROUP, INC
Entity Type:Organization
Organization Name:NAUTILUS RECOVERY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:VAUGHN
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-795-4066
Mailing Address - Street 1:8033 W SUNSET BLVD # 946
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-2401
Mailing Address - Country:US
Mailing Address - Phone:310-795-4066
Mailing Address - Fax:
Practice Address - Street 1:5803 CORBIN AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1004
Practice Address - Country:US
Practice Address - Phone:734-751-4956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA816290448OtherCCAPPP