MEDICARE: EMPOWERED FOR EXCELLENCE BEHAVIORAL HEALTH CALIFORNIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1104467158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPOWERED FOR EXCELLENCE BEHAVIORAL HEALTH CALIFORNIA LLC

Provider Business Mailing Address
First Line	:	3170 W CENTRAL AVE STE D
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43606-2945
Country	:	US
Telephone Number	:	567-316-7231
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 STOCKER ST
Second Line	:
City	:	VIEW PARK
State	:	CA
Zip	:	90008-5108
Country	:	US
Telephone Number	:	419-699-2859
Fax Number	:

Authorized Official
Title or Position	:	CONSULTANT
Name	:	MR. CARL FRANK BLAZIK
Credential	:
Telephone Number	:	419-366-3974

Provider Enumeration Date	:	10/01/2019
Last Update Date	:	06/14/2021

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