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General NPI Number Information
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NPI Number | 1972888170
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Entity Type | Organization
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Legal Business Name | WINGS OF REFUGE, INC.
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Dates
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Enumeration Date | 10/19/2011
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Last Update Date | 10/19/2011
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Provider Practice Location Address
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Address Line | 3751 S HARVARD BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90018-4546
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Country | US
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Telephone | 323-373-2700
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Fax | 323-733-2120
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Provider Business Mailing Address
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Address Line | 5777 W CENTURY BLVD SUITE 910
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City | LOS ANGELES
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State | CA
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Zip | 90045-5600
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Country | US
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Telephone | 310-670-6767
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Fax | 310-670-2626
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | RENEE G MONCITO
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Credential |
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Telephone | 310-670-6767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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