Provider Demographics
NPI:1265810311
Name:PRODUCTS FOR RECOVERY MANAGEMENT GROUP, LLC
Entity type:Organization
Organization Name:PRODUCTS FOR RECOVERY MANAGEMENT GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-835-0123
Mailing Address - Street 1:23172 PLAZA POINTE DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAGUNA
Mailing Address - State:CA
Mailing Address - Zip Code:92653-6136
Mailing Address - Country:US
Mailing Address - Phone:657-235-0178
Mailing Address - Fax:657-235-0178
Practice Address - Street 1:24482 CARACAS ST.
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-4167
Practice Address - Country:US
Practice Address - Phone:949-835-0123
Practice Address - Fax:657-235-0178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51101207RA0401X
324500000X
CA300021AP261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1235407131OtherNPI
CAF51931Medicare UPIN