Healthcare Provider Details

I. General information

NPI: 1558932558
Provider Name (Legal Business Name): STUDIO 64 RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 LAUREL CANYON BLVD STE 600
NORTH HOLLYWOOD CA
91606-1568
US

IV. Provider business mailing address

6400 LAUREL CANYON BLVD STE 600
NORTH HOLLYWOOD CA
91606-1568
US

V. Phone/Fax

Practice location:
  • Phone: 818-800-9702
  • Fax:
Mailing address:
  • Phone: 818-800-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TALIN MOURADIAN
Title or Position: SECRETARY
Credential:
Phone: 818-800-9702