MEDICARE: MJB TRANSITIONAL RECOVERY, INC.

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	261Q00000X	Clinic/Center	190288BN	CA

General Provider Information

NPI Number	:	1598118911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MJB TRANSITIONAL RECOVERY, INC.

Provider Business Mailing Address
First Line	:	11152 S MAIN ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-1953
Country	:	US
Telephone Number	:	323-777-2491
Fax Number	:

Provider Business Practice Location Address
First Line	:	11152 S MAIN ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-1953
Country	:	US
Telephone Number	:	323-777-2491
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DARRELL NELMS
Credential	:	BA
Telephone Number	:	323-777-2491

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	07/20/2016

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