MEDICARE: WINGS OF REFUGE

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	251300000X	Local Education Agency (LEA)	190434AN	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	197098	OTHER	CA	MEDI-CAL PROVIDER

General Provider Information

NPI Number	:	1609093699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINGS OF REFUGE

Provider Business Mailing Address
First Line	:	5777 W CENTURY BLVD
Second Line	:	STE 910
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5600
Country	:	US
Telephone Number	:	310-670-6767
Fax Number	:	310-670-2626

Provider Business Practice Location Address
First Line	:	5777 W CENTURY BLVD
Second Line	:	STE 910
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5600
Country	:	US
Telephone Number	:	310-670-6767
Fax Number	:	310-670-2626

Authorized Official
Title or Position	:	CEO
Name	:	RENEE MONCITO
Credential	:
Telephone Number	:	310-670-6767

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	08/22/2020

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Directions to “WINGS OF REFUGE ” Practice Location

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