Provider Demographics
NPI:1679013288
Name:THE DUCK HOUSE, LLC
Entity Type:Organization
Organization Name:THE DUCK HOUSE, LLC
Other - Org Name:THE DUCK HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:KOHZAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:714-598-7467
Mailing Address - Street 1:952 DAHLIA AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:952 DAHLIA AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1739
Practice Address - Country:US
Practice Address - Phone:714-598-7467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300358AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility