Healthcare Provider Details

I. General information

NPI: 1588943203
Provider Name (Legal Business Name): THIRD STREET TREATMENT PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4067 W 3RD ST
LOS ANGELES CA
90020-3120
US

IV. Provider business mailing address

4067 W 3RD ST
LOS ANGELES CA
90020-3120
US

V. Phone/Fax

Practice location:
  • Phone: 818-635-9380
  • Fax: 818-337-0365
Mailing address:
  • Phone: 818-635-9380
  • Fax: 818-337-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number190695
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190695
License Number StateCA

VIII. Authorized Official

Name: CHRISTOPHER BATHUM
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PROGRAM ADMIN ADP
Phone: 818-635-9380