Healthcare Provider Details

I. General information

NPI: 1407520497
Provider Name (Legal Business Name): EMPOWERED FOR EXCELLENCE, EMPOWERING YOUTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3170 W CENTRAL AVE STE G
TOLEDO OH
43606-2945
US

IV. Provider business mailing address

3170 W CENTRAL AVE STE G
TOLEDO OH
43606-2945
US

V. Phone/Fax

Practice location:
  • Phone: 310-981-3332
  • Fax:
Mailing address:
  • Phone: 310-981-3332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JONATHAN JAMES
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 310-981-3332