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General NPI Number Information
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NPI Number | 1699690560
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Entity Type | Organization
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Legal Business Name | PROVIDENCE DETOX
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Dates
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Enumeration Date | 08/11/2026
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Last Update Date | 08/11/2026
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Provider Practice Location Address
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Address Line | 20454 HEMMINGWAY ST
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City | WINNETKA
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State | CA
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Zip | 91306-2249
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Country | US
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Telephone | 818-940-0308
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Fax | 310-758-0982
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Provider Business Mailing Address
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Address Line | 20454 HEMMINGWAY ST
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City | WINNETKA
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State | CA
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Zip | 91306-2249
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Country | US
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Telephone | 818-940-0308
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Fax | 310-758-0982
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Authorized Official
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Title or Position | CEO
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Name | MHER DANIELYAN
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Credential |
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Telephone | 818-940-0308
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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 |
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License Number State |
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