=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528442936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERVICE INDUSTRIES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 06/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15250 VENTURA BLVD SUITE 1100
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-217-1052
-----------------------------------------------------
Fax | 310-456-1860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29160 HEATHERCLIFF RD., STE. 200
-----------------------------------------------------
City | MALIBU
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-217-1052
-----------------------------------------------------
Fax | 310-456-1860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MS. KELLY STEPHENSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-579-1004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 190856AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 190069AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------