Provider Demographics
NPI:1780012674
Name:AMERICAN INDIAN CHANGING SPIRITS
Entity Type:Organization
Organization Name:AMERICAN INDIAN CHANGING SPIRITS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN OUDHEUSDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MSW
Authorized Official - Phone:310-679-9126
Mailing Address - Street 1:2120 W WILLIAMS ST
Mailing Address - Street 2:BUILDING #1
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-3636
Mailing Address - Country:US
Mailing Address - Phone:562-388-8118
Mailing Address - Fax:562-388-8117
Practice Address - Street 1:2120 W WILLIAMS ST
Practice Address - Street 2:BUILDING #2
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-3636
Practice Address - Country:US
Practice Address - Phone:562-388-8118
Practice Address - Fax:562-388-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190239AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility