Healthcare Provider Details

I. General information

NPI: 1942506860
Provider Name (Legal Business Name): PACIFIC LODGE YOUTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2011
Last Update Date: 02/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22030 SHERMAN WAY STE 215
CANOGA PARK CA
91303-1883
US

IV. Provider business mailing address

22030 SHERMAN WAY STE 215
CANOGA PARK CA
91303-1883
US

V. Phone/Fax

Practice location:
  • Phone: 818-347-1577
  • Fax:
Mailing address:
  • Phone: 818-347-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA E ALEGRIA
Title or Position: PRESIDENT CEO
Credential:
Phone: 818-657-3104