Healthcare Provider Details

I. General information

NPI: 1851917033
Provider Name (Legal Business Name): CASA DE LAS AMIGAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 N OAK KNOLL AVE
PASADENA CA
91101
US

IV. Provider business mailing address

160 N EL MOLINO AVE
PASADENA CA
91101-1805
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL

VIII. Authorized Official

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