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General NPI Number Information
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NPI Number | 1073887329
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Entity Type | Organization
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Legal Business Name | LA FUENTE HOLLYWOOD TREATMENT CENTER LLC
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Dates
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Enumeration Date | 03/05/2012
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Last Update Date | 03/05/2012
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Provider Practice Location Address
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Address Line | 5718 FOUNTAIN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90028-8516
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Country | US
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Telephone | 323-464-2947
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Fax | 323-366-9339
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Provider Business Mailing Address
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Address Line | 5718 FOUNTAIN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90028-8516
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Country | US
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Telephone | 323-464-2947
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Fax | 323-366-9339
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MANUEL RODRIGUEZ
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Credential |
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Telephone | 323-464-2947
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 190725AP
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License Number State | CA
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