Provider Demographics
NPI:1700634730
Name:CORRAL CANYON RECOVERY,LLC
Entity Type:Organization
Organization Name:CORRAL CANYON RECOVERY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JANAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONCALVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-813-8116
Mailing Address - Street 1:4607 LAKEVIEW CANYON RD # 300
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4028
Mailing Address - Country:US
Mailing Address - Phone:714-813-8116
Mailing Address - Fax:818-301-2519
Practice Address - Street 1:1752 CORRAL CANYON RD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2906
Practice Address - Country:US
Practice Address - Phone:714-813-8116
Practice Address - Fax:818-301-2519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility