Basic Information
| Provider Information | |||||||||
| NPI: | 1942506860 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC LODGE YOUTH SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22030 SHERMAN WAY STE 215 | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913031883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183471577 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22030 SHERMAN WAY STE 215 | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913031883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183471577 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2011 | ||||||||
| LastUpdateDate: | 02/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALEGRIA | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 8186573104 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PACIFIC LODGE YOUTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
No ID Information.