MEDICARE: PROJECT RETURN PEER SUPPORT NETWORK

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	225400000X	Rehabilitation Practitioner
2	251S00000X	Community/Behavioral Health Agency	NA	CA
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1548386626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROJECT RETURN PEER SUPPORT NETWORK

Provider Business Mailing Address
First Line	:	2677 ZOE AVE SUITE #304
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4195
Country	:	US
Telephone Number	:	323-346-0960
Fax Number	:	323-346-0966

Provider Business Practice Location Address
First Line	:	2677 ZOE AVE SUITE #304
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4195
Country	:	US
Telephone Number	:	323-346-0960
Fax Number	:	323-346-0966

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	GUYTON COLANTUONO
Credential	:
Telephone Number	:	323-346-0960

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	03/16/2018

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