Healthcare Provider Details

I. General information

NPI: 1700549102
Provider Name (Legal Business Name): MONTAGE RECOVERY CA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18016 VALLEY VISTA BLVD
ENCINO CA
91316-4223
US

IV. Provider business mailing address

203 S ORANGE DR
LOS ANGELES CA
90036-3010
US

V. Phone/Fax

Practice location:
  • Phone: 805-437-6515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JOANN ZUNIGA
Title or Position: DIRECTOR
Credential:
Phone: 805-616-0719