Healthcare Provider Details

I. General information

NPI: 1245878917
Provider Name (Legal Business Name): PROFOUND TREATMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 WESTWOOD BLVD STE 350
LOS ANGELES CA
90025-4674
US

IV. Provider business mailing address

21300 VICTORY BLVD STE 540
WOODLAND HILLS CA
91367-8089
US

V. Phone/Fax

Practice location:
  • Phone: 310-600-2395
  • Fax:
Mailing address:
  • Phone: 310-600-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TREVIS SMITH
Title or Position: CEO
Credential:
Phone: 310-600-2395