Healthcare Provider Details

I. General information

NPI: 1275739401
Provider Name (Legal Business Name): EMQ HOLLYGROVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N EL CENTRO AVE
LOS ANGELES CA
90038-3805
US

IV. Provider business mailing address

950 S WESTMORELAND AVE APT. 202
LOS ANGELES CA
90006-5669
US

V. Phone/Fax

Practice location:
  • Phone: 323-463-2119
  • Fax:
Mailing address:
  • Phone: 213-252-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number322D00000X
License Number StateCA

VIII. Authorized Official

Name: MR. DERIC MARTEZ HORTON
Title or Position: DAY REHABILITATION SPECIALIST
Credential: BA MHRS
Phone: 323-463-2119