Provider Demographics
NPI:1093268849
Name:WOODGLEN WEST DETOX
Entity Type:Organization
Organization Name:WOODGLEN WEST DETOX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:P
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-578-2962
Mailing Address - Street 1:771 W ORANGETHORPE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2806
Mailing Address - Country:US
Mailing Address - Phone:714-879-0929
Mailing Address - Fax:
Practice Address - Street 1:1401 W ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4632
Practice Address - Country:US
Practice Address - Phone:714-869-3270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODGLEN RECOVERY JUNCTION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300042DN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility