Basic Information
| Provider Information | |||||||||
| NPI: | 1104961101 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRESS HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1666 | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956671666 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | PROGRESS HOUSE PERINATAL FACILITY | ||||||||
| Address2: | 5494 PONY EXPRESS TRAIL | ||||||||
| City: | CAMINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306443758 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9163177230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 090002EN | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | 090002GN | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | 090002HN | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | 090002IN | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | 090002FN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 090913 | 01 | CA | DRUG MEDI-CAL | OTHER | 090918 | 01 | CA | DRUG MEDI-CAL | OTHER |