1376146050 NPI number — EXODUS RECOVERY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376146050 NPI number — EXODUS RECOVERY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXODUS RECOVERY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AMHS EXODUS CRISIS RESIDENTIAL BE WELL ORANGE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376146050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9808 VENICE BLVD STE 700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90232-6824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-945-3350
Provider Business Mailing Address Fax Number:
310-945-3355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
265 S ANITA DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-3346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-410-3505
Provider Business Practice Location Address Fax Number:
714-410-3529
Provider Enumeration Date:
11/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SKOROHOD
Authorized Official First Name:
LEEANN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
310-945-3350

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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