Provider Demographics
NPI:1215373055
Name:AEGIS TREATMENT CENTERS, LLC
Entity Type:Organization
Organization Name:AEGIS TREATMENT CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-205-9005
Mailing Address - Street 1:7246 REMMET AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11776 MARIPOSA RD
Practice Address - Street 2:# 103
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1622
Practice Address - Country:US
Practice Address - Phone:760-956-2462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHDC70081FMedicaid