Provider Demographics
NPI:1821872797
Name:IRONWOOD LAKE HOUSE
Entity Type:Organization
Organization Name:IRONWOOD LAKE HOUSE
Other - Org Name:IRONWOOD LAKE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-457-6302
Mailing Address - Street 1:12424 WILSHIRE BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1035
Mailing Address - Country:US
Mailing Address - Phone:310-457-6302
Mailing Address - Fax:310-457-6318
Practice Address - Street 1:24 POND HILL RD
Practice Address - Street 2:
Practice Address - City:SOUTH CHINA
Practice Address - State:ME
Practice Address - Zip Code:04358-5009
Practice Address - Country:US
Practice Address - Phone:310-457-6302
Practice Address - Fax:310-457-6318
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IRONWOOD MAINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility