Provider Demographics
NPI:1194250258
Name:EXPERIENCE RECOVERY DETOX & RESIDENTIAL LLC.
Entity type:Organization
Organization Name:EXPERIENCE RECOVERY DETOX & RESIDENTIAL LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHU
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-951-8514
Mailing Address - Street 1:3919 W HAZARD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-2625
Mailing Address - Country:US
Mailing Address - Phone:800-870-3973
Mailing Address - Fax:855-275-5428
Practice Address - Street 1:3919 W HAZARD AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-2625
Practice Address - Country:US
Practice Address - Phone:714-713-5272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility