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General NPI Number Information
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NPI Number | 1356726913
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Entity Type | Organization
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Legal Business Name | PASSAGES MALIBU PHP, LLC
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Dates
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Enumeration Date | 07/24/2015
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Last Update Date | 07/24/2015
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Provider Practice Location Address
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Address Line | 1728 ABBOT KINNEY BLVD #103
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City | VENICE
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State | CA
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Zip | 90291-4839
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Country | US
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Telephone | 866-619-7013
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Fax |
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Provider Business Mailing Address
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Address Line | 6428 MEADOWS CT
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City | MALIBU
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State | CA
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Zip | 90265-4492
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Country | US
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Telephone | 310-589-2880
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Fax | 310-464-6933
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Authorized Official
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Title or Position | COO
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Name | MARINA JO MAHONEY
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Credential |
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Telephone | 310-589-2880
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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 | 190835AP
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License Number State | CA
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