Provider Demographics
NPI:1427594639
Name:PHOENIX HOUSES OF LOS ANGELES, INC.
Entity Type:Organization
Organization Name:PHOENIX HOUSES OF LOS ANGELES, INC.
Other - Org Name:PHOENIX ACADEMY AT LAKE VIEW TERRACE
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR VICE PRESIDENT AND EXECUTIVE
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-686-3011
Mailing Address - Street 1:11600 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:91342-6506
Mailing Address - Country:US
Mailing Address - Phone:818-686-3000
Mailing Address - Fax:818-686-3016
Practice Address - Street 1:11600 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LAKE VIEW TERRACE
Practice Address - State:CA
Practice Address - Zip Code:91342-6506
Practice Address - Country:US
Practice Address - Phone:818-686-3000
Practice Address - Fax:818-896-4859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-11
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190115BN324500000X
CA1912227313245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children