Provider Demographics
NPI:1700626629
Name:ADDICTION SPECIALIST OF SOUTHERN CALIFORNIA, INC.
Entity type:Organization
Organization Name:ADDICTION SPECIALIST OF SOUTHERN CALIFORNIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-390-4730
Mailing Address - Street 1:66 ENGLISH SADDLE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1839
Mailing Address - Country:US
Mailing Address - Phone:949-390-4730
Mailing Address - Fax:949-627-8107
Practice Address - Street 1:4000 MACARTHUR BLVD
Practice Address - Street 2:SUITE 600 EAST TOWER
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2517
Practice Address - Country:US
Practice Address - Phone:949-390-4730
Practice Address - Fax:949-627-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder