Provider Demographics
NPI:1952815110
Name:BEACHSIDE RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:BEACHSIDE RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKELVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-948-6086
Mailing Address - Street 1:PO BOX 511330
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15548 SONORA ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-1936
Practice Address - Country:US
Practice Address - Phone:949-393-4070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACHSIDE RECOVERY CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-27
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300315DP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility