Provider Demographics
NPI:1891202982
Name:LAKE STREET DETOX LLC
Entity Type:Organization
Organization Name:LAKE STREET DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:NICCOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-279-1165
Mailing Address - Street 1:402 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5928
Mailing Address - Country:US
Mailing Address - Phone:877-699-8511
Mailing Address - Fax:949-209-2677
Practice Address - Street 1:402 LAKE ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-5928
Practice Address - Country:US
Practice Address - Phone:877-699-8511
Practice Address - Fax:949-209-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility