Healthcare Provider Details

I. General information

NPI: 1134366115
Provider Name (Legal Business Name): INDEPENDENCE COMMUNITY TREATMENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 E AVENUE R ROOM 118, 119, 217
LITTLEROCK CA
93543-4106
US

IV. Provider business mailing address

19231 VICTORY BLVD SUITE 554
RESEDA CA
91335-6308
US

V. Phone/Fax

Practice location:
  • Phone: 818-776-1755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number960001358
License Number StateCA

VIII. Authorized Official

Name: ALEX BRANZBURG
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 818-776-1755