Healthcare Provider Details

I. General information

NPI: 1639613821
Provider Name (Legal Business Name): HILLSIDES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 AVENUE 64
PASADENA CA
91105-2711
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105-2711
US

V. Phone/Fax

Practice location:
  • Phone: 323-254-2274
  • Fax:
Mailing address:
  • Phone: 323-254-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MARISOL M LARA
Title or Position: QA MANAGER ADMINISTRATION
Credential:
Phone: 323-254-2274