Healthcare Provider Details

I. General information

NPI: 1588306344
Provider Name (Legal Business Name): 11037 ANZIO HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11037 ANZIO RD
LOS ANGELES CA
90077-2201
US

IV. Provider business mailing address

300 CORPORATE POINTE
CULVER CITY CA
90230-7614
US

V. Phone/Fax

Practice location:
  • Phone: 310-592-2415
  • Fax:
Mailing address:
  • Phone: 310-592-2415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER CHO
Title or Position: CEO
Credential:
Phone: 310-592-2415