Provider Demographics
NPI:1356726913
Name:PASSAGES MALIBU PHP, LLC
Entity type:Organization
Organization Name:PASSAGES MALIBU PHP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-589-2880
Mailing Address - Street 1:6428 MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4492
Mailing Address - Country:US
Mailing Address - Phone:310-589-2880
Mailing Address - Fax:310-464-6933
Practice Address - Street 1:1728 ABBOT KINNEY BLVD
Practice Address - Street 2:#103
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-4839
Practice Address - Country:US
Practice Address - Phone:866-619-7013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190835AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility