Basic Information
| Provider Information | |||||||||
| NPI: | 1295812626 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX HOUSE ORANGE COUNTY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11600 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186863000 | ||||||||
| FaxNumber: | 8188964859 | ||||||||
| Practice Location | |||||||||
| Address1: | 1207 E FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149539373 | ||||||||
| FaxNumber: | 7149537573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MORRIS | ||||||||
| AuthorizedOfficialFirstName: | SHAWNA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & EXECUTIVE D | ||||||||
| AuthorizedOfficialTelephone: | 8186863011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 300605606 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 324500000X | 300033CN | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 3245S0500X | 300605606 | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 324500000X | 300033AN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 300605606 | 01 | CA | STATE LICENSE NUMBER- ADP | OTHER | 1612 | 01 | CA | CALIFORNIA | OTHER | 8047 | 01 | CA | DRUG MEDI-CAL PROVIDER NUMB | OTHER |