Provider Demographics
NPI:1851895361
Name:GOLDWING RECOVERY CO.
Entity Type:Organization
Organization Name:GOLDWING RECOVERY CO.
Other - Org Name:GOLDWING RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-305-4147
Mailing Address - Street 1:3031 N SAN FERNANDO BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-4704
Mailing Address - Country:US
Mailing Address - Phone:832-312-9611
Mailing Address - Fax:
Practice Address - Street 1:14942 HAMLIN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1406
Practice Address - Country:US
Practice Address - Phone:832-312-9611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherGOLDWING RECOVERY