Healthcare Provider Details

I. General information

NPI: 1194242966
Provider Name (Legal Business Name): NOVO DETOX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 07/21/2022
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11346 THURSTON PL
LOS ANGELES CA
90049-2429
US

IV. Provider business mailing address

10533 WASHINGTON BLVD
CULVER CITY CA
90232-3311
US

V. Phone/Fax

Practice location:
  • Phone: 602-430-7543
  • Fax:
Mailing address:
  • Phone: 310-663-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MATTHEW ZIERING
Title or Position: CFO
Credential:
Phone: 310-663-8890