Basic Information
| Provider Information | |||||||||
| NPI: | 1801319967 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MALIBU BEACH RECOVERY CENTER, LLC | ||||||||
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| OtherOrganizationName: | MALIBU BEACH RECOVERY CENTER - BRENTWOOD HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 WINDY RIDGE PKWY #210 SOUTH | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788130505 | ||||||||
| FaxNumber: | 6788130505 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S SALTAIR AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900494114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788130505 | ||||||||
| FaxNumber: | 6788130505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2017 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | DOCKERY | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF RCM | ||||||||
| AuthorizedOfficialTelephone: | 6788130505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERMEND HEALTH, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190562CP | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.