Provider Demographics
NPI:1639677768
Name:LOCAL 92109 LLC
Entity Type:Organization
Organization Name:LOCAL 92109 LLC
Other - Org Name:BOARDWALK RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-206-0081
Mailing Address - Street 1:1940 GARNET AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1940 GARNET AVE STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109
Practice Address - Country:US
Practice Address - Phone:619-206-0081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder