Healthcare Provider Details

I. General information

NPI: 1669997060
Provider Name (Legal Business Name): ELEMENTAL TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1976 S LA CIENEGA BLVD STE 668
LOS ANGELES CA
90034-1627
US

IV. Provider business mailing address

1976 S LA CIENEGA BLVD STE 668
LOS ANGELES CA
90034-1627
US

V. Phone/Fax

Practice location:
  • Phone: 310-721-6447
  • Fax:
Mailing address:
  • Phone: 310-721-6447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ALAN BOND
Title or Position: CFO
Credential:
Phone: 310-457-0128