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General NPI Number Information
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NPI Number | 1114541547
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Entity Type | Organization
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Legal Business Name | SOUL DETOX AND RECOVERY
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Dates
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Enumeration Date | 06/01/2020
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Last Update Date | 06/01/2020
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Provider Practice Location Address
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Address Line | 8124 SHADYGLADE AVE
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91605-1331
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Country | US
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Telephone | 747-223-2611
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Fax |
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Provider Business Mailing Address
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Address Line | 11834 GILMORE ST UNIT 5
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91606-2847
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Country | US
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Telephone | 818-355-5642
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JACLYN CHORBAJIAN
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Credential |
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Telephone | 818-355-5642
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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 |
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License Number State |
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