Basic Information
| Provider Information | |||||||||
| NPI: | 1366870941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EXODUS FOUNDATION FOR RECOVERY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EXODUS MLK UCC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9808 VENICE BLVD | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902322732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109453350 | ||||||||
| FaxNumber: | 3108407023 | ||||||||
| Practice Location | |||||||||
| Address1: | 12021 S WILMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900593019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622954617 | ||||||||
| FaxNumber: | 5622954665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKOROHOD | ||||||||
| AuthorizedOfficialFirstName: | LEEANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3109453350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00527 | 01 | LEGAL ENTITY NUMBER | OTHER | 7890 | 05 | CA | MEDICAID |