Basic Information
| Provider Information | |||||||||
| NPI: | 1861558413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEGIS TREATMENT CENTERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7246 REMMET AVE | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913031531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182060360 | ||||||||
| FaxNumber: | 8182060381 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 COLOMA WAY | ||||||||
| Address2: | SUITE # A, B AND C | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956614480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167746647 | ||||||||
| FaxNumber: | 9167746456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | DODD | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT-CEO | ||||||||
| AuthorizedOfficialTelephone: | 8182060360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | HDC70085F | 05 | CA | MEDICAID |