Basic Information
| Provider Information | |||||||||
| NPI: | 1972236198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXODUS RECOVERY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9808 VENICE BLVD STE 700 | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902326824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109453350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9808 VENICE BLVD STE 700 | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902326824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109453350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2022 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGISTERED NURSE | ||||||||
| AuthorizedOfficialTelephone: | 7144103500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.