Healthcare Provider Details

I. General information

NPI: 1699690560
Provider Name (Legal Business Name): PROVIDENCE DETOX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20454 HEMMINGWAY ST
WINNETKA CA
91306-2249
US

IV. Provider business mailing address

20454 HEMMINGWAY ST
WINNETKA CA
91306-2249
US

V. Phone/Fax

Practice location:
  • Phone: 818-940-0308
  • Fax: 310-758-0982
Mailing address:
  • Phone: 818-940-0308
  • Fax: 310-758-0982

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: MHER DANIELYAN
Title or Position: CEO
Credential:
Phone: 818-940-0308