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General NPI Number Information
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NPI Number | 1598340796
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Entity Type | Organization
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Legal Business Name | GRATITUDE LODGE
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Dates
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Enumeration Date | 03/10/2021
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Last Update Date | 03/10/2021
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Provider Practice Location Address
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Address Line | 20132 REDLANDS DR
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-1324
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Country | US
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Telephone | 781-330-2124
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Fax |
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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 | CO FOUNDER
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Name | MARK WILLIAMS
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Credential |
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Telephone | 781-330-2124
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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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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