Provider Demographics
NPI:1629441308
Name:PALM HOUSE, INC.
Entity Type:Organization
Organization Name:PALM HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:DICCION
Authorized Official - Last Name:CASACLANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-830-7803
Mailing Address - Street 1:2515 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90810-1519
Mailing Address - Country:US
Mailing Address - Phone:310-830-7803
Mailing Address - Fax:310-830-6606
Practice Address - Street 1:2515 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90810-1519
Practice Address - Country:US
Practice Address - Phone:310-830-7803
Practice Address - Fax:310-830-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190040AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility