Provider Demographics
NPI:1992216063
Name:HOPE CANYON
Entity Type:Organization
Organization Name:HOPE CANYON
Other - Org Name:HOPE CANYON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:NIZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-804-6503
Mailing Address - Street 1:1515 NW 167TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5106
Mailing Address - Country:US
Mailing Address - Phone:786-923-3376
Mailing Address - Fax:
Practice Address - Street 1:2821 LANGE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-3109
Practice Address - Country:US
Practice Address - Phone:855-804-6503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty