Healthcare Provider Details

I. General information

NPI: 1528201498
Provider Name (Legal Business Name): MALIBU LIGHTHOUSE TREATMENT CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12517 YERBA BUENA RD
MALIBU CA
90265-2107
US

IV. Provider business mailing address

12517 YERBA BUENA RD
MALIBU CA
90265-2107
US

V. Phone/Fax

Practice location:
  • Phone: 310-457-8067
  • Fax:
Mailing address:
  • Phone: 310-457-8067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190612AP
License Number StateCA

VIII. Authorized Official

Name: DR. PEGGY LOCKE
Title or Position: CLAIMS ADMINISTRATOR
Credential: DC
Phone: 805-488-5159