=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134596356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA NEW LIFE DETOX AND RECOVERY HOMES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2015
-----------------------------------------------------
Last Update Date | 03/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18134 CHASE ST
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-775-1749
-----------------------------------------------------
Fax | 818-626-9749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18134 CHASE STREET CHASE STREET
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-775-1749
-----------------------------------------------------
Fax | 818-626-9749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. EMMANUEL OYEBABOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-775-1749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 190851AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------