Provider Demographics
NPI:1437637014
Name:O/G RECOVERY
Entity Type:Organization
Organization Name:O/G RECOVERY
Other - Org Name:GRACE RECOVERY COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-499-3112
Mailing Address - Street 1:12801 MILBANK ST
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1354
Mailing Address - Country:US
Mailing Address - Phone:310-499-3112
Mailing Address - Fax:
Practice Address - Street 1:6078 SELMA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6415
Practice Address - Country:US
Practice Address - Phone:310-499-3112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility