Provider Demographics
NPI:1184342099
Name:EXCELLENCE COMMUNITY REHABILITATION PROGRAM LLC
Entity type:Organization
Organization Name:EXCELLENCE COMMUNITY REHABILITATION PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASKEW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:424-789-0439
Mailing Address - Street 1:1607 E PALMDALE BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7801
Mailing Address - Country:US
Mailing Address - Phone:424-789-0439
Mailing Address - Fax:
Practice Address - Street 1:37025 LA CONTEMPO AVE
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7351
Practice Address - Country:US
Practice Address - Phone:424-789-0439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA197610283OtherADULT RESIDENTIAL FACILITY LICENSE