Provider Demographics
NPI:1992384663
Name:CRESCENT MOON RECOVERY, LLC
Entity type:Organization
Organization Name:CRESCENT MOON RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-706-8898
Mailing Address - Street 1:11770 WARNER AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2661
Mailing Address - Country:US
Mailing Address - Phone:714-464-8474
Mailing Address - Fax:714-948-8883
Practice Address - Street 1:11770 WARNER AVE STE 207
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2661
Practice Address - Country:US
Practice Address - Phone:714-464-8474
Practice Address - Fax:714-948-8883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESCENT MOON RECOVERY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-07
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health