Provider Demographics
NPI:1255732962
Name:EXODUS FOUNDATION
Entity type:Organization
Organization Name:EXODUS FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SKOROHOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-945-3350
Mailing Address - Street 1:9808 VENICE BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6824
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:310-840-7023
Practice Address - Street 1:12021 S WILMINGTON AVE
Practice Address - Street 2:2ND FLOOR IC1-IC7
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:562-295-5916
Practice Address - Fax:562-295-5965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-12
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7890Medicaid