Provider Demographics
NPI:1457891699
Name:PROVIDENCE RECOVERY CENTERS, INC.
Entity type:Organization
Organization Name:PROVIDENCE RECOVERY CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DRUG AND ALCOHOL COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CAS
Authorized Official - Phone:951-443-1715
Mailing Address - Street 1:23703 PIEDRAS RD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-7263
Mailing Address - Country:US
Mailing Address - Phone:951-443-1715
Mailing Address - Fax:951-940-5384
Practice Address - Street 1:23703 PIEDRAS RD
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-7263
Practice Address - Country:US
Practice Address - Phone:951-443-1715
Practice Address - Fax:951-940-5384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility