Provider Demographics
NPI:1053687160
Name:SHATTO STREET
Entity Type:Organization
Organization Name:SHATTO STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:323-988-3744
Mailing Address - Street 1:4715 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1233
Mailing Address - Country:US
Mailing Address - Phone:323-988-3744
Mailing Address - Fax:
Practice Address - Street 1:1543 SHATTO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1718
Practice Address - Country:US
Practice Address - Phone:213-353-4407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIXON RECOVERY INSTITUTE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190622AN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA197336Medicaid