Healthcare Provider Details

I. General information

NPI: 1477216091
Provider Name (Legal Business Name): LOS ANGELES TEEN OUTPATIENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 WILSHIRE BLVD STE 300
LOS ANGELES CA
90036-4436
US

IV. Provider business mailing address

6053 BRISTOL PKWY
CULVER CITY CA
90230-6601
US

V. Phone/Fax

Practice location:
  • Phone: 323-364-6489
  • Fax:
Mailing address:
  • Phone: 323-364-6489
  • Fax: 310-919-0372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRY SCHOSER
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 323-364-6489