MEDICARE: REFUGE RECOVERY HOUSE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1205238508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REFUGE RECOVERY HOUSE, LLC

Provider Business Mailing Address
First Line	:	5081 MONTEZUMA ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-3228
Country	:	US
Telephone Number	:	323-787-7077
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 MELROSE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-3511
Country	:	US
Telephone Number	:	323-787-7077
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER/CEO
Name	:	NOAH PETER MOUNTAIN LEVINE
Credential	:	MA
Telephone Number	:	323-787-7077

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	09/18/2014

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