Basic Information
| Provider Information | |||||||||
| NPI: | 1043542707 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRESS HOUSE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | PROGRESS HOUSE INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2844 COLOMA ST | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956674406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306269240 | ||||||||
| FaxNumber: | 5306268992 | ||||||||
| Practice Location | |||||||||
| Address1: | 2844 COLOMA ST | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956674406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306269240 | ||||||||
| FaxNumber: | 5306268992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2010 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5303444542 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.