Healthcare Provider Details

I. General information

NPI: 1548708365
Provider Name (Legal Business Name): DESIRE 4 CHANGE LIVING IOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17019 SAN JOSE ST
GRANADA HILLS CA
91344-6238
US

IV. Provider business mailing address

17019 SAN JOSE ST
GRANADA HILLS CA
91344-6238
US

V. Phone/Fax

Practice location:
  • Phone: 310-345-9618
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. KIMBERLEE SAFFORE
Title or Position: EXECUTIVE PROGRAM DIRECTOR
Credential:
Phone: 310-345-9618