Provider Demographics
NPI:1760180699
Name:SKYLINE RECOVERY CENTER
Entity Type:Organization
Organization Name:SKYLINE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ZEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOTEH
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:336-339-6856
Mailing Address - Street 1:1517 S SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3311
Mailing Address - Country:US
Mailing Address - Phone:626-319-6296
Mailing Address - Fax:
Practice Address - Street 1:1517 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3311
Practice Address - Country:US
Practice Address - Phone:626-319-6296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-20
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
INSURERSOtherINSURERS