Healthcare Provider Details

I. General information

NPI: 1659573905
Provider Name (Legal Business Name): GATEWAYS PERCY VILLAGE B
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1891 EFFIE ST
LOS ANGELES CA
90026-1711
US

IV. Provider business mailing address

3455 PERCY ST
LOS ANGELES CA
90023-1716
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-2000
  • Fax:
Mailing address:
  • Phone: 323-268-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number198600612
License Number StateCA

VIII. Authorized Official

Name: MARA PELSMAN
Title or Position: CEO
Credential:
Phone: 323-644-2000