Healthcare Provider Details

I. General information

NPI: 1043190226
Provider Name (Legal Business Name): VANGUARD LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28310 ROADSIDE DR STE 218
AGOURA HILLS CA
91301-4942
US

IV. Provider business mailing address

28310 ROADSIDE DR STE 218
AGOURA HILLS CA
91301-4942
US

V. Phone/Fax

Practice location:
  • Phone: 646-275-2111
  • Fax:
Mailing address:
  • Phone: 646-275-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSHUA WOLF
Title or Position: PARTNER
Credential:
Phone: 646-275-2111