Healthcare Provider Details

I. General information

NPI: 1598487027
Provider Name (Legal Business Name): MONTAGE RECOVERY CA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3341 COUNTRY CLUB DR
LOS ANGELES CA
90019-3535
US

IV. Provider business mailing address

203 S ORANGE DR
LOS ANGELES CA
90036-3010
US

V. Phone/Fax

Practice location:
  • Phone: 818-299-3602
  • Fax: 805-830-1565
Mailing address:
  • Phone: 818-299-3602
  • Fax: 805-830-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 3
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: 805-437-6515