MEDICARE: THIRD STREET TREATMENT PARTNERS, 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	:	1912292012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THIRD STREET TREATMENT PARTNERS, LLC

Provider Business Mailing Address
First Line	:	4067 W 3RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-3120
Country	:	US
Telephone Number	:	888-870-2201
Fax Number	:

Provider Business Practice Location Address
First Line	:	4067 W 3RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-3120
Country	:	US
Telephone Number	:	888-870-2201
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CHRIS BATHUM
Credential	:
Telephone Number	:	818-268-7242

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	08/22/2011

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