Provider Demographics
NPI:1659579738
Name:LODGEQUEST
Entity Type:Organization
Organization Name:LODGEQUEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT - SERVICE DELIVERY
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROSICA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:610-486-2280
Mailing Address - Street 1:352 MARSHALLTON THORNDALE RD
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-2063
Mailing Address - Country:US
Mailing Address - Phone:610-486-2280
Mailing Address - Fax:610-384-7258
Practice Address - Street 1:16955 LEMON ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-5139
Practice Address - Country:US
Practice Address - Phone:760-947-8223
Practice Address - Fax:760-947-8225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISIONQUEST NATIONAL LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06-08508251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA04-74049-000Medicaid