Healthcare Provider Details

I. General information

NPI: 1073854147
Provider Name (Legal Business Name): GROWTH EXTENDED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 03/31/2024
Certification Date: 03/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 S SERRANO AVE
LOS ANGELES CA
90020-3604
US

IV. Provider business mailing address

60 N LOTUS AVE
PASADENA CA
91107-3811
US

V. Phone/Fax

Practice location:
  • Phone: 888-948-9998
  • Fax: 888-751-6166
Mailing address:
  • Phone: 888-948-9998
  • Fax: 888-751-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number198207997
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN LEWIS
Title or Position: CFO
Credential:
Phone: 888-948-9998