Healthcare Provider Details

I. General information

NPI: 1699460022
Provider Name (Legal Business Name): GROUNDUP FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 DE SOTO AVE UNIT #426
WOODLAND HILLS CA
91367
US

IV. Provider business mailing address

20929 VENTURA BLVD STE 47
WOODLAND HILLS CA
91364-2334
US

V. Phone/Fax

Practice location:
  • Phone: 323-337-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RONNIE MCCLAIN
Title or Position: OWNER
Credential:
Phone: 323-337-3000