Healthcare Provider Details

I. General information

NPI: 1780129486
Provider Name (Legal Business Name): LOS ANGELES YOUTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2471 N BEACHWOOD DR
LOS ANGELES CA
90068-3004
US

IV. Provider business mailing address

1754 TAFT AVE
LOS ANGELES CA
90028-5705
US

V. Phone/Fax

Practice location:
  • Phone: 323-962-0430
  • Fax:
Mailing address:
  • Phone: 323-366-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number197603055
License Number StateCA

VIII. Authorized Official

Name: MARK SUPPER
Title or Position: PRESIDENT/CEO
Credential:
Phone: 323-467-8466