Healthcare Provider Details

I. General information

NPI: 1083923429
Provider Name (Legal Business Name): PHOENIX HOUSE ORANGE COUNTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

IV. Provider business mailing address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax:
Mailing address:
  • Phone: 714-953-9373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number300605606
License Number StateCA

VIII. Authorized Official

Name: POURIA ABBASSI
Title or Position: SENIOR VP, REGIONAL DIRECTOR
Credential: P.E.
Phone: 818-686-3011