Provider Demographics
NPI:1083923429
Name:PHOENIX HOUSE ORANGE COUNTY, INC.
Entity Type:Organization
Organization Name:PHOENIX HOUSE ORANGE COUNTY, INC.
Other - Org Name:CYS PHOENIX ACADEMY OF ORANGE COUNTY
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR VP, REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:POURIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABBASSI
Authorized Official - Suffix:
Authorized Official - Credentials:PE
Authorized Official - Phone:818-686-3011
Mailing Address - Street 1:1207 E FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4206
Mailing Address - Country:US
Mailing Address - Phone:714-953-9373
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4206
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3006056063245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300605606OtherCA DEPT OF ALCOHOL AND DRUG PROGRAM
CA1612OtherLEGAL ENTITY NUMBER