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General NPI Number Information
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NPI Number | 1902270960
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Entity Type | Organization
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Legal Business Name | REFUGE RECOVERY HOUSE
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Dates
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Enumeration Date | 11/13/2015
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Last Update Date | 11/13/2015
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Provider Practice Location Address
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Address Line | 1007 MANZANITA ST
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City | LOS ANGELES
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State | CA
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Zip | 90029-3011
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Country | US
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Telephone | 323-787-7077
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Fax |
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Provider Business Mailing Address
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Address Line | 4302 MELROSE AVE STE 5C
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City | LOS ANGELES
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State | CA
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Zip | 90029-3511
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Country | US
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Telephone | 323-787-7077
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR/COFOUNDER
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Name | SHANNON FOWLER
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Credential |
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Telephone | 323-787-7077
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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 | 190853BP
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License Number State | CA
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