Basic Information
| Provider Information | |||||||||
| NPI: | 1164145686 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXODUS RECOVERY, INC. | ||||||||
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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: | 3109453355 | ||||||||
| Practice Location | |||||||||
| Address1: | 5150 W GOLDLEAF CIR STE 405 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900561663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243846140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2022 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | SKOROHOD | ||||||||
| AuthorizedOfficialFirstName: | LEEANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 3109453350 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251X00000X | N | Agencies | Supports Brokerage | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.