Organization
LAKE STREET DETOX LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ERIC NICCOLE (CEO)
(949) 279-1165
Entity
Organization
Contact information
Practice address
402 LAKE ST, HUNTINGTON BEACH, CA 92648-5928
(877) 699-8511
(949) 209-2677
Mailing address
402 LAKE ST, HUNTINGTON BEACH, CA 92648-5928
(877) 699-8511
(949) 209-2677
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Enumeration date
01/10/2018
Last updated
01/10/2018
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