Provider Demographics
NPI:1598340796
Name:GRATITUDE LODGE
Entity Type:Organization
Organization Name:GRATITUDE LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-330-2124
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 1:20132 REDLANDS DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1324
Practice Address - Country:US
Practice Address - Phone:781-330-2124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRATITUDE LODGE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder