1720385883 NPI number — WINGS OF REFUGE, 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 1720385883 NPI number — WINGS OF REFUGE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINGS OF REFUGE, 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:
WINGS OF RECOVERY-EDGEWOOD ACADEMY
Provider Other Organization Name Type Code:
3
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:
1720385883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14135 FAIRGROVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PUENTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91746-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-670-6767
Provider Business Practice Location Address Fax Number:
310-670-2626
Provider Enumeration Date:
02/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MONCITO
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
310-670-6767

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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