Basic Information
| Provider Information | |||||||||
| NPI: | 1932572146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAFE REFUGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUBSTANCE ABUSE FOUNDATION OF LONG BEACH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1041 REDONDO AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908043928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629875722 | ||||||||
| FaxNumber: | 5629874586 | ||||||||
| Practice Location | |||||||||
| Address1: | 3119 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908044932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629875722 | ||||||||
| FaxNumber: | 5629874586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2015 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROMO | ||||||||
| AuthorizedOfficialFirstName: | KATHRYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5629875722 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190077AHN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 1989 | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |