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General NPI Number Information
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NPI Number | 1912355850
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Entity Type | Organization
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Legal Business Name | THE HOUSE OF THE RISING SON
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Dates
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Enumeration Date | 06/01/2016
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Last Update Date | 06/01/2016
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Provider Practice Location Address
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Address Line | 521 W AVENIDA DE LOS LOBOS MARINOS
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-4374
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Country | US
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Telephone | 503-793-8919
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Fax |
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Provider Business Mailing Address
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Address Line | 521 W AVENIDA DE LOS LOBOS MARINOS
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-4374
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Country | US
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Telephone | 503-793-8919
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Fax |
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Authorized Official
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Title or Position | OWNER/CFO
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Name | JACQUELINE F BAHU
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Credential |
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Telephone | 503-793-8919
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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 | 300633AP
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License Number State | CA
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