Provider Demographics
NPI:1225321524
Name:WINGS OF REFUGE, INC
Entity Type:Organization
Organization Name:WINGS OF REFUGE, INC
Other - Org Name:WINGS OF RECOVERY - NON RESIDENTIAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
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 1:38345 30TH ST E
Practice Address - Street 2:SUITE A-2
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4980
Practice Address - Country:US
Practice Address - Phone:661-267-7124
Practice Address - Fax:661-267-1549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
1649577206OtherDRUG MEDI-CAL
1013213933OtherDRUG MEDI-CAL
1386940211OtherDRUG MED-ICAL
1922304856OtherDRUG MEDI-CAL
1720385883OtherDRUG MEDI-CAL