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General NPI Number Information
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NPI Number | 1578084679
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Entity Type | Organization
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Legal Business Name | CASA BELLA SOBER LIVING - WEST, LLC
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Dates
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Enumeration Date | 06/29/2017
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Last Update Date | 06/29/2017
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Provider Practice Location Address
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Address Line | 1937 FEDERAL AVE
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City | LOS ANGELES
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State | CA
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Zip | 90025-5415
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Country | US
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Telephone | 310-913-0029
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Fax | 310-913-0029
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Provider Business Mailing Address
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Address Line | PO BOX 12410
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City | MARINA DEL REY
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State | CA
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Zip | 90295-3410
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Country | US
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Telephone | 310-913-0029
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Fax |
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Authorized Official
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Title or Position | CO-OWNER/OPERATOR
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Name | FIONA A RAY
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Credential | LMFT
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Telephone | 310-913-0029
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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 | 190937AP
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License Number State | CA
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