Basic Information
| Provider Information | |||||||||
| NPI: | 1841929916 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXODUS RECOVERY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9808 VENICE BLVD STE 700 | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902326824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109453350 | ||||||||
| FaxNumber: | 3109453355 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N BLACKSTONE AVE | ||||||||
| Address2: | OFFICE 1 & 2, COMMUNITY ROOM 105 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937011939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595381230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | SKOROHOD | ||||||||
| AuthorizedOfficialFirstName: | LEEANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3109453350 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.