Healthcare Provider Details

I. General information

NPI: 1821872797
Provider Name (Legal Business Name): IRONWOOD LAKE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 POND HILL RD
SOUTH CHINA ME
04358-5009
US

IV. Provider business mailing address

12424 WILSHIRE BLVD STE 800
LOS ANGELES CA
90025-1035
US

V. Phone/Fax

Practice location:
  • Phone: 310-457-6302
  • Fax: 310-457-6318
Mailing address:
  • Phone: 310-457-6302
  • Fax: 310-457-6318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DEBORA GARCIA
Title or Position: RCM MANAGER
Credential:
Phone: 310-457-6302