Provider Demographics
NPI:1417252032
Name:ADOLESCENCE'S LAST RESORT
Entity Type:Organization
Organization Name:ADOLESCENCE'S LAST RESORT
Other - Org Name:THE LAST RESORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIGNON
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:HEARST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-523-6910
Mailing Address - Street 1:3125 MCHENRY AVENUE STE D.
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-523-6910
Mailing Address - Fax:209-523-6912
Practice Address - Street 1:218 E. ORANGEBURG AVENUE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-523-6900
Practice Address - Fax:209-523-6912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA507004599324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility