Healthcare Provider Details

I. General information

NPI: 1629511670
Provider Name (Legal Business Name): DELIANN-LUCILE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5739 CHESLEY AVE
LOS ANGELES CA
90043-2423
US

IV. Provider business mailing address

5731 W SLAUSON AVE STE 210
CULVER CITY CA
90230-6982
US

V. Phone/Fax

Practice location:
  • Phone: 323-299-0822
  • Fax: 323-299-0819
Mailing address:
  • Phone: 310-215-8900
  • Fax: 310-215-8907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARY L DAVIS
Title or Position: CEO
Credential:
Phone: 310-215-8900