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General NPI Number Information
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NPI Number | 1578193678
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Entity Type | Organization
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Legal Business Name | GRATITUDE LODGE LLC
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Dates
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Enumeration Date | 01/17/2020
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Last Update Date | 01/17/2020
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Provider Practice Location Address
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Address Line | 20182 KLINE DR
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-1312
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Country | US
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Telephone | 657-218-9958
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Fax | 888-411-0151
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Provider Business Mailing Address
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Address Line | 3849 CHATWIN AVE
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City | LONG BEACH
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State | CA
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Zip | 90808-2004
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | BROOKS BUTLER
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Credential |
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Telephone | 657-218-9958
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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