Provider Demographics
NPI:1366977217
Name:KEITH ANGELIN
Entity type:Organization
Organization Name:KEITH ANGELIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED ALCOHOL AND DRUG COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELIN
Authorized Official - Suffix:
Authorized Official - Credentials:LAADC
Authorized Official - Phone:949-939-9222
Mailing Address - Street 1:1510 S COAST HWY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-5355
Mailing Address - Country:US
Mailing Address - Phone:949-939-9222
Mailing Address - Fax:866-929-6316
Practice Address - Street 1:1510 S COAST HWY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5355
Practice Address - Country:US
Practice Address - Phone:949-939-9222
Practice Address - Fax:866-929-6316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALR02541116101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty