Provider Demographics
NPI:1689268294
Name:LA JOLLA RECOVERY INC
Entity Type:Organization
Organization Name:LA JOLLA RECOVERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-877-3422
Mailing Address - Street 1:1804 GARNET AVE # 233
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1446, 1448 & 1450 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3023
Practice Address - Country:US
Practice Address - Phone:858-877-3422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA JOLLA RECOVERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA370159DPOtherDHCS