Basic Information
| Provider Information | |||||||||
| NPI: | 1427594639 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX HOUSES OF LOS ANGELES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHOENIX ACADEMY AT LAKE VIEW TERRACE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11600 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186863000 | ||||||||
| FaxNumber: | 8186863016 | ||||||||
| Practice Location | |||||||||
| Address1: | 11600 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186863000 | ||||||||
| FaxNumber: | 8188964859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2017 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORRIS | ||||||||
| AuthorizedOfficialFirstName: | SHAWNA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT AND EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 8186863011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 191222731 | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 324500000X | 190115BN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.