Healthcare Provider Details

I. General information

NPI: 1053784264
Provider Name (Legal Business Name): SAFE REFUGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 E 7TH ST
LONG BEACH CA
90804-4932
US

IV. Provider business mailing address

1041 REDONDO AVE
LONG BEACH CA
90804-3928
US

V. Phone/Fax

Practice location:
  • Phone: 562-987-5722
  • Fax: 562-987-4586
Mailing address:
  • Phone: 562-987-5722
  • Fax: 562-987-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number190077CN
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190077AHN
License Number StateCA

VIII. Authorized Official

Name: KATHYRN ROMO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 562-987-5722