Healthcare Provider Details

I. General information

NPI: 1699079376
Provider Name (Legal Business Name): STEP UP ON SECOND STREET, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6762 LEXINGTON AVE STE A
LOS ANGELES CA
90038-1217
US

IV. Provider business mailing address

6762 LEXINGTON AVE STE A
LOS ANGELES CA
90038-1217
US

V. Phone/Fax

Practice location:
  • Phone: 323-380-7590
  • Fax: 323-380-7591
Mailing address:
  • Phone: 323-380-7590
  • Fax: 323-380-7591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TOD LIPKA
Title or Position: PRESIDENT & CEO
Credential:
Phone: 310-901-9142