Provider Demographics
NPI:1912355850
Name:THE HOUSE OF THE RISING SON
Entity type:Organization
Organization Name:THE HOUSE OF THE RISING SON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:BAHU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-793-8919
Mailing Address - Street 1:521 W AVENIDA DE LOS LOBOS MARINOS
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4374
Mailing Address - Country:US
Mailing Address - Phone:503-793-8919
Mailing Address - Fax:
Practice Address - Street 1:521 W AVENIDA DE LOS LOBOS MARINOS
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4374
Practice Address - Country:US
Practice Address - Phone:503-793-8919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300633AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility