MEDICARE: REFUGE RECOVERY HOUSE

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	190853BP	CA

General Provider Information

NPI Number	:	1902270960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REFUGE RECOVERY HOUSE

Provider Business Mailing Address
First Line	:	4302 MELROSE AVE STE 5C
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-3511
Country	:	US
Telephone Number	:	323-787-7077
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 MANZANITA ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-3011
Country	:	US
Telephone Number	:	323-787-7077
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR/COFOUNDER
Name	:	SHANNON FOWLER
Credential	:
Telephone Number	:	323-787-7077

Provider Enumeration Date	:	11/13/2015
Last Update Date	:	11/13/2015

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Directions to “REFUGE RECOVERY HOUSE ” Practice Location

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