=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104689744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADWOOD REHAB CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2024
-----------------------------------------------------
Last Update Date | 02/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7744 RADFORD AVE
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91605-2859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-635-7098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14144 VENTURA BLVD STE 280
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91423-2769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-635-7098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. AKOP KESABLYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-635-7098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------