Provider Demographics
NPI:1902808744
Name:THE FELLOWSHIP CENTER ALCOHOL SERVICES PROGRAM, INC.
Entity Type:Organization
Organization Name:THE FELLOWSHIP CENTER ALCOHOL SERVICES PROGRAM, INC.
Other - Org Name:THE FELLOWSHIP CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICICCIO
Authorized Official - Suffix:
Authorized Official - Credentials:ASW, LAADC-CA
Authorized Official - Phone:760-745-8478
Mailing Address - Street 1:737 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4404
Mailing Address - Country:US
Mailing Address - Phone:760-745-8478
Mailing Address - Fax:760-745-1176
Practice Address - Street 1:737 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4404
Practice Address - Country:US
Practice Address - Phone:760-745-8478
Practice Address - Fax:760-745-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370009AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility