Provider Demographics
NPI:1043768807
Name:SACRED SPACE HEALING & RETREAT CENTER INTERNATIONAL, INC.
Entity Type:Organization
Organization Name:SACRED SPACE HEALING & RETREAT CENTER INTERNATIONAL, INC.
Other - Org Name:SACRED SPACE RETREATS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANUSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMEN-RA
Authorized Official - Suffix:
Authorized Official - Credentials:CNC
Authorized Official - Phone:707-894-0063
Mailing Address - Street 1:627 CHERRY CREEK RD.
Mailing Address - Street 2:BOX 311
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425
Mailing Address - Country:US
Mailing Address - Phone:707-894-0063
Mailing Address - Fax:800-914-6360
Practice Address - Street 1:627 CHERRY CREEK RD.
Practice Address - Street 2:BOX 311
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425
Practice Address - Country:US
Practice Address - Phone:707-894-0063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490039AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility