Provider Demographics
NPI:1801319967
Name:MALIBU BEACH RECOVERY CENTER, LLC
Entity type:Organization
Organization Name:MALIBU BEACH RECOVERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF RCM
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DOCKERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-813-0505
Mailing Address - Street 1:2300 WINDY RIDGE PKWY #210 SOUTH
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339
Mailing Address - Country:US
Mailing Address - Phone:678-813-0505
Mailing Address - Fax:678-813-0505
Practice Address - Street 1:101 S SALTAIR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4114
Practice Address - Country:US
Practice Address - Phone:678-813-0505
Practice Address - Fax:678-813-0505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERMEND HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-20
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190562CP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility