Provider Demographics
NPI:1245657873
Name:PAT MOORE DETOX, LLC
Entity type:Organization
Organization Name:PAT MOORE DETOX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AREL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEISTER-ALDAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-960-0080
Mailing Address - Street 1:536 HAMILTON ST
Mailing Address - Street 2:UNITS A, B AND C
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2617
Mailing Address - Country:US
Mailing Address - Phone:949-646-2830
Mailing Address - Fax:949-646-3028
Practice Address - Street 1:536 HAMILTON ST
Practice Address - Street 2:UNITS A, B AND C
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2617
Practice Address - Country:US
Practice Address - Phone:949-646-2830
Practice Address - Fax:949-646-3028
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPROUT HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300274AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility