Provider Demographics
NPI:1437310695
Name:THE CANYON AT PEACE PARK, LLC
Entity Type:Organization
Organization Name:THE CANYON AT PEACE PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BIGSBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MSW
Authorized Official - Phone:310-457-3209
Mailing Address - Street 1:210 WESTWOOD PLACE,
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7554
Mailing Address - Country:US
Mailing Address - Phone:615-342-3200
Mailing Address - Fax:
Practice Address - Street 1:2900 S. KANAN DUME ROAD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2792
Practice Address - Country:US
Practice Address - Phone:310-457-3209
Practice Address - Fax:310-457-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190441BP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility