Basic Information
Provider Information | |||||||||
NPI: | 1487090221 | ||||||||
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: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 201 D ST STE G | ||||||||
Address2: |   | ||||||||
City: | MARYSVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 959015957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5307427747 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2013 | ||||||||
LastUpdateDate: | 11/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DODD | ||||||||
AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
AuthorizedOfficialMiddleName: | CHARLES | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4152059005 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
ID | Type | State | Issuer | Description | HDC70075F | 05 | CA |   | MEDICAID |