Basic Information
| Provider Information | |||||||||
| NPI: | 1336687821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXWELL | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236648940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4445 BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900292702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236648940 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2017 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | R1236821116 | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.