Provider Demographics
NPI:1083943005
Name:EXODUS RECOVERY, INC.
Entity Type:Organization
Organization Name:EXODUS RECOVERY, INC.
Other - Org Name:EXODUS CENTRAL CONNECTIONS
Other - Org Type:Other Name
Authorized Official - Title/Position:SR VP OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SKOROHOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-945-3350
Mailing Address - Street 1:9808 VENICE BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2732
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:310-840-7023
Practice Address - Street 1:4308 30TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1314
Practice Address - Country:US
Practice Address - Phone:310-945-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3220Medicaid