MEDICARE: IRENE'S HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1063163905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IRENE'S HOME LLC

Provider Business Mailing Address
First Line	:	1916 SOUTH 43RD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113
Country	:	US
Telephone Number	:	619-538-7599
Fax Number	:	619-393-0448

Provider Business Practice Location Address
First Line	:	1916 SOUTH 43RD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113
Country	:	US
Telephone Number	:	619-538-7599
Fax Number	:	619-393-0448

Authorized Official
Title or Position	:	CEO
Name	:	PORTIA SMITH
Credential	:
Telephone Number	:	619-538-7599

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	01/12/2022

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