MEDICARE: KLEAN LONG BEACH, WA, 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

General Provider Information

NPI Number	:	1912245259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KLEAN LONG BEACH, WA, LLC

Provider Business Mailing Address
First Line	:	9000 W SUNSET BLVD
Second Line	:	650 B
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-5801
Country	:	US
Telephone Number	:	310-740-4843
Fax Number	:	310-657-4420

Provider Business Practice Location Address
First Line	:	211 PIONEER RD W
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631-3654
Country	:	US
Telephone Number	:	360-642-3105
Fax Number	:	360-642-2766

Authorized Official
Title or Position	:	CEO
Name	:	ANDREW SPANSWICK
Credential	:
Telephone Number	:	310-435-8096

Provider Enumeration Date	:	01/22/2013
Last Update Date	:	05/12/2014

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