Provider Demographics
NPI:1881723344
Name:THE TWELFTH STEP HOUSE OF SAN DIEGO, INC.
Entity type:Organization
Organization Name:THE TWELFTH STEP HOUSE OF SAN DIEGO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II, CATC
Authorized Official - Phone:619-287-5460
Mailing Address - Street 1:5855 STREAMVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-3910
Mailing Address - Country:US
Mailing Address - Phone:619-287-5460
Mailing Address - Fax:619-287-5040
Practice Address - Street 1:5855 STREAMVIEW DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-3910
Practice Address - Country:US
Practice Address - Phone:619-287-5460
Practice Address - Fax:619-287-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370003AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility