Basic Information
| Provider Information | |||||||||
| NPI: | 1114171642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EXODUS RECOVERY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EXODUS MENTAL HEALTH WALK-IN CTR - ESCONDIDO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9808 VENICE BLVD STE 700 | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902326824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109453350 | ||||||||
| FaxNumber: | 3108407023 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 S ESCONDIDO BLVD | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920256017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607461146 | ||||||||
| FaxNumber: | 7607967758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2008 | ||||||||
| LastUpdateDate: | 10/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | SKOROHOD | ||||||||
| AuthorizedOfficialFirstName: | LEEANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP, OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3109453350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CHC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 37LC | 05 | CA | MEDICAID |