Provider Demographics
NPI:1720597511
Name:CHILDREN'S RECOVERY CENTER 1, LLC
Entity Type:Organization
Organization Name:CHILDREN'S RECOVERY CENTER 1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICCUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-425-1171
Mailing Address - Street 1:3777 S BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7320
Mailing Address - Country:US
Mailing Address - Phone:408-558-3640
Mailing Address - Fax:408-340-1519
Practice Address - Street 1:3777 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7320
Practice Address - Country:US
Practice Address - Phone:408-558-3640
Practice Address - Fax:408-340-1519
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVATIONS HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-25
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren