Basic Information
Provider Information | |||||||||
NPI: | 1700226685 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHOENIX HOUSES OF LOS ANGELES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11600 ELDRIDGE AVE | ||||||||
Address2: |   | ||||||||
City: | LAKE VIEW TERRACE | ||||||||
State: | CA | ||||||||
PostalCode: | 913426506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8186863000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11465 KAGEL CANYON ST | ||||||||
Address2: |   | ||||||||
City: | LAKE VIEW TERRACE | ||||||||
State: | CA | ||||||||
PostalCode: | 913426505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8186863000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2013 | ||||||||
LastUpdateDate: | 12/02/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SALAZAR | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8186863015 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 190115DN | CA | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
ID | Type | State | Issuer | Description | 1945 | 01 | CA | MEDICAL | OTHER |