Provider Demographics
NPI:1386197267
Name:THE BEACON HOUSE ASSOCIATION OF SAN PEDRO
Entity Type:Organization
Organization Name:THE BEACON HOUSE ASSOCIATION OF SAN PEDRO
Other - Org Name:BEACON HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGEMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-514-4940
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90733-0328
Mailing Address - Country:US
Mailing Address - Phone:310-514-4940
Mailing Address - Fax:310-831-0070
Practice Address - Street 1:132 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3702
Practice Address - Country:US
Practice Address - Phone:310-514-4940
Practice Address - Fax:310-831-0070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190006BN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility