Provider Demographics
NPI:1679857775
Name:SUMMIT ESTATE RECOVERY CENTERS LLC
Entity type:Organization
Organization Name:SUMMIT ESTATE RECOVERY CENTERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGEI
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-498-3626
Mailing Address - Street 1:7280 BLUE HILL DR STE 7
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-3624
Mailing Address - Country:US
Mailing Address - Phone:800-701-6997
Mailing Address - Fax:323-576-5345
Practice Address - Street 1:4145 OLD ADOBE RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-3724
Practice Address - Country:US
Practice Address - Phone:800-701-6997
Practice Address - Fax:323-576-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QM0850X, 261QR0405X, 276400000X
CA440017AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA430100APOtherDHCS
CA430077CPOtherDHCS