Healthcare Provider Details

I. General information

NPI: 1063798965
Provider Name (Legal Business Name): MALIBU CALIFORNIA MODEL DRUG TREATMENT CENTER,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30101 AGOURA CT STE 103
AGOURA HILLS CA
91301-4301
US

IV. Provider business mailing address

30101 AGOURA CT STE 103
AGOURA HILLS CA
91301-4301
US

V. Phone/Fax

Practice location:
  • Phone: 818-532-6243
  • Fax: 818-532-6244
Mailing address:
  • Phone: 818-532-6243
  • Fax: 818-532-6244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190729BP
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: IRINA SHMELEVA
Title or Position: CFO
Credential:
Phone: 818-585-0027