Healthcare Provider Details

I. General information

NPI: 1821625138
Provider Name (Legal Business Name): ASC TREATMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2457 ENDICOTT ST
LOS ANGELES CA
90032-3098
US

IV. Provider business mailing address

2457 ENDICOTT ST
LOS ANGELES CA
90032-3047
US

V. Phone/Fax

Practice location:
  • Phone: 323-227-5252
  • Fax:
Mailing address:
  • Phone: 323-227-5252
  • Fax: 323-227-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DONETTA JACKSON
Title or Position: ADMINISTRATOR
Credential: MFT
Phone: 323-318-2520