Healthcare Provider Details

I. General information

NPI: 1619616927
Provider Name (Legal Business Name): MONTAGE RECOVERY CA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14339 VALLEY VISTA BLVD
SHERMAN OAKS CA
91423-4027
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 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