Provider Demographics
NPI:1902270960
Name:REFUGE RECOVERY HOUSE
Entity Type:Organization
Organization Name:REFUGE RECOVERY HOUSE
Other - Org Name:REFUGE RECOVERY CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR/COFOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-787-7077
Mailing Address - Street 1:4302 MELROSE AVE STE 5C
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-3511
Mailing Address - Country:US
Mailing Address - Phone:323-787-7077
Mailing Address - Fax:
Practice Address - Street 1:1007 MANZANITA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-3011
Practice Address - Country:US
Practice Address - Phone:323-787-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190853BP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility