Provider Demographics
NPI:1013459569
Name:COASTAL RECOVERY, INC.
Entity Type:Organization
Organization Name:COASTAL RECOVERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:EDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-413-1390
Mailing Address - Street 1:11851 WISTERIA AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2654
Mailing Address - Country:US
Mailing Address - Phone:949-642-4150
Mailing Address - Fax:949-642-3441
Practice Address - Street 1:11851 WISTERIA AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2654
Practice Address - Country:US
Practice Address - Phone:949-642-4150
Practice Address - Fax:949-642-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility