Basic Information
| Provider Information | |||||||||
| NPI: | 1730525585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEGIS TREATMENT CENTERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7246 REMMET AVE | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913031531 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4129 STATE ST | ||||||||
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| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931101848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059644795 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | DODD | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4152059005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | HDC70072F | 05 | CA | MEDICAID |