Provider Demographics
NPI:1023781903
Name:CRYSTAL RIDGE RECOVERY
Entity type:Organization
Organization Name:CRYSTAL RIDGE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEEVAKA
Authorized Official - Middle Name:PRASANNA
Authorized Official - Last Name:WEERASINGHE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:951-288-7962
Mailing Address - Street 1:2247 TIFFANY LN
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9246
Mailing Address - Country:US
Mailing Address - Phone:951-288-7962
Mailing Address - Fax:909-383-1388
Practice Address - Street 1:2748 S ERIN WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4184
Practice Address - Country:US
Practice Address - Phone:951-288-7962
Practice Address - Fax:909-383-1388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility