Healthcare Provider Details

I. General information

NPI: 1376339630
Provider Name (Legal Business Name): DETOXERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3147 E SIERRA MADRE BLVD
PASADENA CA
91107-2037
US

IV. Provider business mailing address

3147 E SIERRA MADRE BLVD
PASADENA CA
91107-2037
US

V. Phone/Fax

Practice location:
  • Phone: 626-437-0500
  • Fax:
Mailing address:
  • Phone: 626-437-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANT AGADJANIAN
Title or Position: CFO
Credential:
Phone: 626-437-0500