Basic Information
| Provider Information | |||||||||
| NPI: | 1821086976 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOCIAL MODEL RECOVERY SYSTEMS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 E ROWLAND ST | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263323145 | ||||||||
| FaxNumber: | 6269744164 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 S WESTLAKE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900572906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134839201 | ||||||||
| FaxNumber: | 2133531740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | DADES | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6263323145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOCIAL MODEL RECOVERY SYSTEMS, INC. | ||||||||
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| AuthorizedOfficialCredential: | MA, MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190008BN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.