Provider Demographics
NPI:1518455302
Name:PAX HOUSE INC.
Entity Type:Organization
Organization Name:PAX HOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:DESIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:CADC-CAS
Authorized Official - Phone:626-808-0335
Mailing Address - Street 1:1717 E MENDOCINO STREET
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001
Mailing Address - Country:US
Mailing Address - Phone:626-398-3897
Mailing Address - Fax:626-270-4640
Practice Address - Street 1:2052 LAKE AVE STE F
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001
Practice Address - Country:US
Practice Address - Phone:626-808-0335
Practice Address - Fax:626-270-4640
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAX HOUSE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-26
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190732BP261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder