Provider Demographics
NPI:1003086653
Name:INNERCEPT
Entity Type:Organization
Organization Name:INNERCEPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MONROE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-334-2233
Mailing Address - Street 1:12424 WILSHIRE BLVD SUITE 800
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-457-6302
Mailing Address - Fax:310-457-6318
Practice Address - Street 1:1115 IRONWOOD DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4936
Practice Address - Country:US
Practice Address - Phone:208-665-7178
Practice Address - Fax:208-765-6972
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALTIORHEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-10
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness