Provider Demographics
NPI:1407346513
Name:SHAMANIC LIVING CENTER
Entity Type:Organization
Organization Name:SHAMANIC LIVING CENTER
Other - Org Name:RECOVERY IN ACTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROPIERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-344-7633
Mailing Address - Street 1:484 PLEASANT VALLEY ROAD STE 4
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9101
Mailing Address - Country:US
Mailing Address - Phone:530-344-7633
Mailing Address - Fax:530-497-5202
Practice Address - Street 1:484 PLEASANT VALLEY ROAD STE 4
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9101
Practice Address - Country:US
Practice Address - Phone:530-344-7633
Practice Address - Fax:530-497-5202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAMANIC LIVING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-14
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder