Healthcare Provider Details

I. General information

NPI: 1619333002
Provider Name (Legal Business Name): INTEGRITY TREATMENT PROGRAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 WILSHIRE BLVD STE 206
LOS ANGELES CA
90025-1000
US

IV. Provider business mailing address

12301 WILSHIRE BLVD STE 206
LOS ANGELES CA
90025-1000
US

V. Phone/Fax

Practice location:
  • Phone: 310-294-9030
  • Fax:
Mailing address:
  • Phone: 310-294-9030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: YESHAIA BLAKENEY
Title or Position: CEO
Credential:
Phone: 310-294-9030