=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942624606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELA MCMAHON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2014
-----------------------------------------------------
Last Update Date | 02/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1043 S SUNSHINE AVE APT 14
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-871-7345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1043 S SUNSHINE AVE APT 14
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-871-7345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO / FOUNDER
-----------------------------------------------------
Name | ANGELA NICOLE MCMAHON
-----------------------------------------------------
Credential | IMF, EDD (C)
-----------------------------------------------------
Telephone | 619-871-7345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------