Basic Information
Provider Information
NPI: 1235600545
EntityType: 2
ReplacementNPI:  
OrganizationName: EXODUS RECOVERY, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: EXODUS AB109 ESCONDIDO
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 1520 S ESCONDIDO BLVD
Address2:  
City: ESCONDIDO
State: CA
PostalCode: 920256017
CountryCode: US
TelephoneNumber: 7607967760
FaxNumber: 7607967758
Other Information
ProviderEnumerationDate: 12/12/2018
LastUpdateDate: 01/07/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SKOROHOD
AuthorizedOfficialFirstName: LEEANN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: COO
AuthorizedOfficialTelephone: 3109453350
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251S00000X  Y AgenciesCommunity/Behavioral Health 

No ID Information.


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