Provider Demographics
NPI:1578193678
Name:GRATITUDE LODGE LLC
Entity Type:Organization
Organization Name:GRATITUDE LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKS
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:657-218-9958
Mailing Address - Street 1:3849 CHATWIN AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20182 KLINE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1312
Practice Address - Country:US
Practice Address - Phone:657-218-9958
Practice Address - Fax:888-411-0151
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRATITUDE LODGE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility