Provider Demographics
NPI:1609093699
Name:WINGS OF REFUGE
Entity Type:Organization
Organization Name:WINGS OF REFUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONCITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-670-6767
Mailing Address - Street 1:5777 W CENTURY BLVD
Mailing Address - Street 2:STE 910
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5600
Mailing Address - Country:US
Mailing Address - Phone:310-670-6767
Mailing Address - Fax:310-670-2626
Practice Address - Street 1:5777 W CENTURY BLVD
Practice Address - Street 2:STE 910
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5600
Practice Address - Country:US
Practice Address - Phone:310-670-6767
Practice Address - Fax:310-670-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190434AN251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA197098OtherMEDI-CAL PROVIDER