Provider Demographics
NPI:1184148165
Name:HOWER LODGE, INC.
Entity type:Organization
Organization Name:HOWER LODGE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CCO / MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-701-1959
Mailing Address - Street 1:33171 PASEO CERVEZA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4824
Mailing Address - Country:US
Mailing Address - Phone:949-701-1959
Mailing Address - Fax:
Practice Address - Street 1:26166 CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352
Practice Address - Country:US
Practice Address - Phone:909-338-3851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360113AP261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA620869OtherTHE JOINT COMMISSION
CA300733APOtherDHCS: DETOX, IMS, & RECOVERY/TREATMENT SERVICES
CA360113APOtherDHCS: DETOX, IMS & RECOVERY/TREATMENT SERVICES LICENSE