Basic Information
Provider Information | |||||||||
NPI: | 1669923124 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTSIDE SOBER LIVING CENTERS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROMISES MALIBU VISTA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 670549 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752670549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6155677282 | ||||||||
FaxNumber: | 6152618912 | ||||||||
Practice Location | |||||||||
Address1: | 20786 COOL OAK WAY | ||||||||
Address2: |   | ||||||||
City: | MALIBU | ||||||||
State: | CA | ||||||||
PostalCode: | 902655318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4242352337 | ||||||||
FaxNumber: | 3109430438 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2016 | ||||||||
LastUpdateDate: | 01/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAPLESDEN | ||||||||
AuthorizedOfficialFirstName: | CHERYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR DIRECTOR RCM | ||||||||
AuthorizedOfficialTelephone: | 6155103708 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ELEMENTS BEHAVIORAL HEALTH, INC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC, CHC, CHPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 198601437 | CA | N |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   | 323P00000X | 197608528 | CA | Y |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   |
No ID Information.