Provider Demographics
NPI:1891571659
Name:417 SOUTH RIVER LLC
Entity Type:Organization
Organization Name:417 SOUTH RIVER LLC
Other - Org Name:417 RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-485-6563
Mailing Address - Street 1:1595 GRAND AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2450
Mailing Address - Country:US
Mailing Address - Phone:760-485-6563
Mailing Address - Fax:
Practice Address - Street 1:33050 ANTELOPE RD STE 201202
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2489
Practice Address - Country:US
Practice Address - Phone:760-485-6563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health