Basic Information
| Provider Information | |||||||||
| NPI: | 1093268849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODGLEN WEST DETOX | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 771 W ORANGETHORPE AVE | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928322806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148790929 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1401 W ORANGETHORPE AVE | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928334632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148693270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2016 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7145782962 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WOODGLEN RECOVERY JUNCTION, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 300042DN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.