Healthcare Provider Details

I. General information

NPI: 1710428628
Provider Name (Legal Business Name): GROWTH EXTENDED, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/31/2024
Certification Date: 03/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15743 COVELLO ST
LAKE BALBOA CA
91406-3120
US

IV. Provider business mailing address

60 N LOTUS AVE
PASADENA CA
91107-3811
US

V. Phone/Fax

Practice location:
  • Phone: 888-948-9998
  • Fax: 888-751-6166
Mailing address:
  • Phone: 888-948-9998
  • Fax: 888-751-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190794AP
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number190794AP
License Number StateCA

VIII. Authorized Official

Name: JOHN LEWIS
Title or Position: CFO
Credential:
Phone: 888-948-9998