Provider Demographics
NPI:1083479216
Name:GRATITUDE LODGE LLC
Entity Type:Organization
Organization Name:GRATITUDE LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-994-2184
Mailing Address - Street 1:3010 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2535
Mailing Address - Country:US
Mailing Address - Phone:800-994-2184
Mailing Address - Fax:888-411-0151
Practice Address - Street 1:3010 E 1ST ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-2535
Practice Address - Country:US
Practice Address - Phone:800-994-2184
Practice Address - Fax:888-411-0151
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRATITUDE LODGE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility