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General NPI Number Information
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NPI Number | 1376829432
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Entity Type | Organization
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Legal Business Name | MC INTYRE HOUSE
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Dates
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Enumeration Date | 11/02/2011
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Last Update Date | 11/02/2011
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Provider Practice Location Address
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Address Line | 544 N KENMORE AVE
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City | LOS ANGELES
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State | CA
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Zip | 90004-6815
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Country | US
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Telephone | 323-662-0855
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Fax | 323-662-0842
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Provider Business Mailing Address
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Address Line | 544 N KENMORE AVE
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City | LOS ANGELES
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State | CA
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Zip | 90004-6815
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Country | US
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Telephone | 323-662-0855
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Fax | 323-662-0842
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. MILTON T MARISTELA
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Credential | R.N.
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Telephone | 323-662-0855
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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 | 190420AN
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License Number State | CA
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