Provider Demographics
NPI:1902396138
Name:COSTA RICA EXECUTIVE REHAB
Entity Type:Organization
Organization Name:COSTA RICA EXECUTIVE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REGIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-445-9293
Mailing Address - Street 1:2716 OAK TREE LN
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6700
Mailing Address - Country:US
Mailing Address - Phone:954-328-9777
Mailing Address - Fax:
Practice Address - Street 1:CALLE HOJA BLANCA
Practice Address - Street 2:
Practice Address - City:ESCAZU
Practice Address - State:SAN JOSE
Practice Address - Zip Code:10201
Practice Address - Country:CR
Practice Address - Phone:888-445-9293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CR MANSION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty