Basic Information
| Provider Information | |||||||||
| NPI: | 1851787188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXODUS RECOVERY CSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4411 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594531008 | ||||||||
| FaxNumber: | 5594532805 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594531008 | ||||||||
| FaxNumber: | 5594532805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | SHARP-RIVAS | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5594531008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 771162 | MN | Y | Hospital Units | Psychiatric Unit |
No ID Information.