Provider Demographics
NPI:1942506860
Name:PACIFIC LODGE YOUTH SERVICES, INC
Entity Type:Organization
Organization Name:PACIFIC LODGE YOUTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALEGRIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-657-3104
Mailing Address - Street 1:22030 SHERMAN WAY STE 215
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1883
Mailing Address - Country:US
Mailing Address - Phone:818-347-1577
Mailing Address - Fax:
Practice Address - Street 1:22030 SHERMAN WAY STE 215
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1883
Practice Address - Country:US
Practice Address - Phone:818-347-1577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACIFIC LODGE YOUTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)