Organization
DANA POINT DETOX LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. NATHANIEL IZZO (ADMIN)
(949) 359-5662
Entity
Organization
Contact information
Practice address
24832 LA PAZ AVE APT B, DANA POINT, CA 92629-5398
(949) 359-5662
(949) 542-3878
Mailing address
24832 LA PAZ AVE APT B, DANA POINT, CA 92629-5398
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
—
—
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
05D2183497
CLIA
—
01
—
300392AP
STATE OF CA
CA
Enumeration date
03/23/2020
Last updated
06/09/2020
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