Healthcare Provider Details

I. General information

NPI: 1922276062
Provider Name (Legal Business Name): CASA DE LAS AMIGAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 N EL MOLINO AVE 173 NORTH OAK KNOLL AVE
PASADENA CA
91101-1805
US

IV. Provider business mailing address

160 N EL MOLINO AVE
PASADENA CA
91101
US

V. Phone/Fax

Practice location:
  • Phone: 626-792-2770
  • Fax: 626-792-5826
Mailing address:
  • Phone: 626-792-2770
  • Fax: 626-792-5826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number190012CN
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS LEAH NOEL RODEMICH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 626-792-2770