Healthcare Provider Details

I. General information

NPI: 1285414573
Provider Name (Legal Business Name): MITCHLOCK FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9061 S NORMANDIE AVE
LOS ANGELES CA
90044-2051
US

IV. Provider business mailing address

10018 S VAN NESS AVE APT 6
LOS ANGELES CA
90047-4145
US

V. Phone/Fax

Practice location:
  • Phone: 323-251-4116
  • Fax:
Mailing address:
  • Phone: 323-251-4116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: CHARLES LOCKETT
Title or Position: OWNER
Credential:
Phone: 323-251-4116