Provider Demographics
NPI:1417456336
Name:VOGUE RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:VOGUE RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYADZHYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-916-8116
Mailing Address - Street 1:16501 SHERMAN WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4122 N 17TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5922
Practice Address - Country:US
Practice Address - Phone:818-916-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5357324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5357OtherARIZONA DEPARTMENT OF HEALTH SERVICES