Provider Demographics
NPI:1124396031
Name:WINGS OF REFUGE
Entity Type:Organization
Organization Name:WINGS OF REFUGE
Other - Org Name:WINGS OF RECOVERY - LOS ANGELES HIGH SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MONCITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-670-6767
Mailing Address - Street 1:5777 W CENTURY BLVD
Mailing Address - Street 2:SUITE 910
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5600
Mailing Address - Country:US
Mailing Address - Phone:310-670-6767
Mailing Address - Fax:310-670-2626
Practice Address - Street 1:4650 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-1831
Practice Address - Country:US
Practice Address - Phone:323-900-2700
Practice Address - Fax:323-936-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization