=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417763749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DECELIS RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2024
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4595 DE CELIS PL
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-3245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-383-5777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 608 N CLYBOURN AVE
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-383-5777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. DAVID HARLOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-383-5777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------