Provider Demographics
NPI:1063899524
Name:SEA CHANGE SANTA MONICA, LP
Entity type:Organization
Organization Name:SEA CHANGE SANTA MONICA, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-877-6030
Mailing Address - Street 1:212 26TH ST
Mailing Address - Street 2:# 102
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1831 WILSHIRE BLVD
Practice Address - Street 2:C
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5777
Practice Address - Country:US
Practice Address - Phone:310-877-6030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190831AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility