Healthcare Provider Details

I. General information

NPI: 1295144921
Provider Name (Legal Business Name): POLARIS TEEN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4981 AMIGO AVE
TARZANA CA
91356-4505
US

IV. Provider business mailing address

4981 AMIGO AVE
TARZANA CA
91356-4505
US

V. Phone/Fax

Practice location:
  • Phone: 818-616-8650
  • Fax:
Mailing address:
  • Phone: 818-616-8650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number198208336
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number198208336
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number198208336
License Number StateCA

VIII. Authorized Official

Name: MR. ARI BROWN
Title or Position: CEO
Credential:
Phone: 818-616-8650