Basic Information
| Provider Information | |||||||||
| NPI: | 1912216680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXODUS RECOVERY, INC. | ||||||||
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| OtherOrganizationName: | EXODUS RECOVERY INC WESTSIDE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9808 VENICE BLVD | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902322732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109453350 | ||||||||
| FaxNumber: | 3108407023 | ||||||||
| Practice Location | |||||||||
| Address1: | 11444 W WASHINGTON BLVD | ||||||||
| Address2: | STE D | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900666024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102539494 | ||||||||
| FaxNumber: | 3102539495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2010 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | SKOROHOD | ||||||||
| AuthorizedOfficialFirstName: | LEEANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP, OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3109453350 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7797 | 05 | CA | MEDICAID | CP707A | 01 | MEDICARE PTAN | OTHER |