Healthcare Provider Details

I. General information

NPI: 1730632159
Provider Name (Legal Business Name): LIFESYNC RECOVERY AND DETOXIFICATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28632 ROADSIDE DR SUITE 235
AGOURA HILLS CA
91301-6064
US

IV. Provider business mailing address

6035 MURPHY WAY
MALIBU CA
90265-4490
US

V. Phone/Fax

Practice location:
  • Phone: 310-951-6340
  • Fax:
Mailing address:
  • Phone: 310-951-6340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190920AP
License Number StateCA

VIII. Authorized Official

Name: GEOFFREY A BOOTH
Title or Position: OWNER
Credential: MD
Phone: 310-951-6340