Healthcare Provider Details

I. General information

NPI: 1972809341
Provider Name (Legal Business Name): PHOENIX HOUSE ORANGE COUNTY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
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 Number261QM0855X
License Number StateCA

VIII. Authorized Official

Name: MR. GEOFF HENDERSON
Title or Position: SENIOR DIRECTOR
Credential:
Phone: 714-953-9373