MEDICARE: LAVELLE YOUTH HOMES

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1861791139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAVELLE YOUTH HOMES

Provider Business Mailing Address
First Line	:	8415 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-3044
Country	:	US
Telephone Number	:	323-759-2569
Fax Number	:	323-759-9425

Provider Business Practice Location Address
First Line	:	7400 W MANCHESTER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-2322
Country	:	US
Telephone Number	:	323-759-2569
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MISS TRACI LA VELLE
Credential	:
Telephone Number	:	323-759-2569

Provider Enumeration Date	:	03/25/2011
Last Update Date	:	03/25/2011

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