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General NPI Number Information
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NPI Number | 1063798965
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Entity Type | Organization
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Legal Business Name | MALIBU CALIFORNIA MODEL DRUG TREATMENT CENTER,INC
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Dates
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Enumeration Date | 10/24/2011
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Last Update Date | 10/18/2024
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Provider Practice Location Address
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Address Line | 30101 AGOURA CT STE 103
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City | AGOURA HILLS
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State | CA
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Zip | 91301-4301
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Country | US
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Telephone | 818-532-6243
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Fax | 818-532-6244
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Provider Business Mailing Address
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Address Line | 30101 AGOURA CT STE 103
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City | AGOURA HILLS
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State | CA
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Zip | 91301-4301
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Country | US
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Telephone | 818-532-6243
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Fax | 818-532-6244
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Authorized Official
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Title or Position | CFO
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Name | IRINA SHMELEVA
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Credential |
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Telephone | 818-585-0027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 190729BP
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 276400000X
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Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
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License Number |
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License Number State |
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