Basic Information
| Provider Information | |||||||||
| NPI: | 1083923429 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX HOUSE ORANGE COUNTY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CYS PHOENIX ACADEMY OF ORANGE COUNTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1207 E FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149539373 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1207 E FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149539373 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 07/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | ABBASSI | ||||||||
| AuthorizedOfficialFirstName: | POURIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP, REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8186863011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.E. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 300605606 | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
| ID | Type | State | Issuer | Description | 300605606 | 01 | CA | CA DEPT OF ALCOHOL AND DRUG PROGRAM | OTHER | 1612 | 01 | CA | LEGAL ENTITY NUMBER | OTHER |