Provider Demographics
NPI:1710160833
Name:COASTAL RECOVERY CENTER
Entity Type:Organization
Organization Name:COASTAL RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-549-8383
Mailing Address - Street 1:19109 GALWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1915
Mailing Address - Country:US
Mailing Address - Phone:310-329-6548
Mailing Address - Fax:
Practice Address - Street 1:117 E HARRY BRIDGES BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5825
Practice Address - Country:US
Practice Address - Phone:310-549-8383
Practice Address - Fax:310-549-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230562302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization