Basic Information
| Provider Information | |||||||||
| NPI: | 1427226968 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESS HOUSE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1666 | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956671666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306269240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5494 PONY EXPRESS TRAIL | ||||||||
| Address2: | HOUSE 1 | ||||||||
| City: | CAMINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306443758 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | AVEY | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5306269240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 090002EN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 0913 | 01 | CA | DRUG MEDI-CAL | OTHER |