Provider Demographics
NPI:1104573633
Name:THE BEACON HOUSE ASSOCIATION OF SAN PEDRO
Entity type:Organization
Organization Name:THE BEACON HOUSE ASSOCIATION OF SAN PEDRO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:CATC I
Authorized Official - Phone:310-514-4940
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90733-0328
Mailing Address - Country:US
Mailing Address - Phone:310-514-4940
Mailing Address - Fax:
Practice Address - Street 1:103 W. 11TH ST.
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-4301
Practice Address - Country:US
Practice Address - Phone:310-514-4940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility