Healthcare Provider Details

I. General information

NPI: 1437797024
Provider Name (Legal Business Name): ANNANDALE BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2019
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 AFTON ST
PASADENA CA
91103-2303
US

IV. Provider business mailing address

1513 PORTIA ST
LOS ANGELES CA
90026-2651
US

V. Phone/Fax

Practice location:
  • Phone: 312-092-2226
  • Fax:
Mailing address:
  • Phone: 310-922-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DARRYL OLIVIER
Title or Position: CEO
Credential:
Phone: 310-922-2264