Provider Demographics
NPI:1386159945
Name:SOUTHERN CALIFORNIA RECOVERY CENTERS OCEANSIDE LLC
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA RECOVERY CENTERS OCEANSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-481-6156
Mailing Address - Street 1:2850 PIO PICO DR STE A-D
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2850 PIO PICO DR STE A-D
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1554
Practice Address - Country:US
Practice Address - Phone:760-517-1758
Practice Address - Fax:949-542-3878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370158AP261QR0405X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
05D2146685OtherCLIA
CACDF00352100OtherSTATE OF CALIFORNIA
CA370158APOtherSTATE OF CALIFORNIA