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General NPI Number Information
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NPI Number | 1508647918
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Entity Type | Organization
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Legal Business Name | SAINT LAWRENCE RECOVERY
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Dates
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Enumeration Date | 10/11/2023
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Last Update Date | 10/11/2023
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Provider Practice Location Address
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Address Line | 12437 HUSTON ST
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City | VALLEY VILLAGE
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State | CA
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Zip | 91607-3517
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Country | US
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Telephone | 747-250-4884
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Fax |
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Provider Business Mailing Address
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Address Line | 14617 ARMINTA ST
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City | PANORAMA CITY
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State | CA
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Zip | 91402-5901
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Country | US
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Telephone | 747-250-4884
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. LAWRENCE KSIDO
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Credential |
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Telephone | 747-250-4884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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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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