Healthcare Provider Details

I. General information

NPI: 1427594639
Provider Name (Legal Business Name): PHOENIX HOUSES OF LOS ANGELES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 ELDRIDGE AVE
LAKE VIEW TERRACE CA
91342-6506
US

IV. Provider business mailing address

11600 ELDRIDGE AVE
LAKE VIEW TERRACE CA
91342-6506
US

V. Phone/Fax

Practice location:
  • Phone: 818-686-3000
  • Fax: 818-896-4859
Mailing address:
  • Phone: 818-686-3000
  • Fax: 818-686-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number191222731
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190115BN
License Number StateCA

VIII. Authorized Official

Name: MS. SHAWNA RENEE MORRIS
Title or Position: SENIOR VICE PRESIDENT AND EXECUTIVE
Credential:
Phone: 818-686-3011