Healthcare Provider Details

I. General information

NPI: 1255732962
Provider Name (Legal Business Name): EXODUS FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 S WILMINGTON AVE 2ND FLOOR IC1-IC7
LOS ANGELES CA
90059-3019
US

IV. Provider business mailing address

9808 VENICE BLVD STE 700
CULVER CITY CA
90232-6824
US

V. Phone/Fax

Practice location:
  • Phone: 562-295-5916
  • Fax: 562-295-5965
Mailing address:
  • Phone: 310-945-3350
  • Fax: 310-840-7023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LEEANN SKOROHOD
Title or Position: SR VP OPERATIONS
Credential:
Phone: 310-945-3350