Basic Information
| Provider Information | |||||||||
| NPI: | 1477885382 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOS ANGELES CENTERS FOR ALCOHOL AND DRUG ABUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11015 BLOOMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906704601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629062676 | ||||||||
| FaxNumber: | 5629062681 | ||||||||
| Practice Location | |||||||||
| Address1: | 11015 BLOOMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906704601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629062676 | ||||||||
| FaxNumber: | 5629062681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2010 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | WIEWEL | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5629062676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190100BN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 191937000 | 01 | CA | MEDICAL | OTHER |