Basic Information
| Provider Information | |||||||||
| NPI: | 1821625138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASC TREATMENT GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2457 ENDICOTT ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900323047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232275252 | ||||||||
| FaxNumber: | 3232279032 | ||||||||
| Practice Location | |||||||||
| Address1: | 2457 ENDICOTT ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900323098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232275252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | DONETTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3233182520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.