Healthcare Provider Details

I. General information

NPI: 1962063123
Provider Name (Legal Business Name): EXODUS RECOVERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 MARENGO ST STE 200B
LOS ANGELES CA
90033-1382
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 323-276-6490
  • Fax:
Mailing address:
  • Phone: 310-945-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LEEANN SKOROHOD
Title or Position: COO
Credential:
Phone: 310-945-3350