MEDICARE: WINGS OF REFUGE, INC.

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	302F00000X	Exclusive Provider Organization

General Provider Information

NPI Number	:	1649577206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINGS OF REFUGE, INC.

Provider Business Mailing Address
First Line	:	5777 W CENTURY BLVD
Second Line	:	SUITE 910
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5600
Country	:	US
Telephone Number	:	310-670-6767
Fax Number	:	310-670-2626

Provider Business Practice Location Address
First Line	:	2516 W. 54TH STREET
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043
Country	:	US
Telephone Number	:	323-296-6573
Fax Number	:	310-670-2626

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	RENEE MONCITO
Credential	:	PHD
Telephone Number	:	310-670-6767

Provider Enumeration Date	:	02/17/2011
Last Update Date	:	02/17/2011

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Directions to “WINGS OF REFUGE, INC. ” Practice Location

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