Provider Demographics
NPI:1275001067
Name:BRYAN'S HOUSE RECOVERY HOME
Entity Type:Organization
Organization Name:BRYAN'S HOUSE RECOVERY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WORTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CCAPP LCI04700315
Authorized Official - Phone:805-674-3131
Mailing Address - Street 1:7760 WHISPERING TRAILS PL
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-6396
Mailing Address - Country:US
Mailing Address - Phone:805-674-3131
Mailing Address - Fax:866-306-5825
Practice Address - Street 1:2000 TRAFFIC WAY
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-1523
Practice Address - Country:US
Practice Address - Phone:805-460-6621
Practice Address - Fax:866-306-5825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-09
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093914152Medicaid