Basic Information
Provider Information | |||||||||
NPI: | 1265597611 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AEGIS TREATMENT CENTERS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7246 REMMET AVE | ||||||||
Address2: |   | ||||||||
City: | CANOGA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 913031531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8182060360 | ||||||||
FaxNumber: | 8182060381 | ||||||||
Practice Location | |||||||||
Address1: | 2055 SAVIERS RD STE 9101112 | ||||||||
Address2: | SUITE 9, 10, 11, 12 | ||||||||
City: | OXNARD | ||||||||
State: | CA | ||||||||
PostalCode: | 930333608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054832253 | ||||||||
FaxNumber: | 8054832255 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2006 | ||||||||
LastUpdateDate: | 01/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DODD | ||||||||
AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
AuthorizedOfficialMiddleName: | CHARLES | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT-CEO | ||||||||
AuthorizedOfficialTelephone: | 8182060360 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
ID | Type | State | Issuer | Description | HDC70079F | 05 | CA |   | MEDICAID |