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General NPI Number Information
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NPI Number | 1700211984
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Entity Type | Organization
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Legal Business Name | THE SOURCE HEALTH AND WELLNESS TREATMENT CENTER
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Dates
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Enumeration Date | 09/06/2013
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Last Update Date | 09/06/2013
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Provider Practice Location Address
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Address Line | 11150 W OLYMPIC BLVD STE 760
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City | LOS ANGELES
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State | CA
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Zip | 90064-1817
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Country | US
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Telephone | 310-477-8140
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Fax |
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Provider Business Mailing Address
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Address Line | 11150 W OLYMPIC BLVD STE 760
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City | LOS ANGELES
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State | CA
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Zip | 90064-1817
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Country | US
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Telephone | 310-477-8140
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Fax |
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Authorized Official
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Title or Position | PRESIDENT AND EXECUTIVE DIRECTOR
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Name | DR. JASON LEVINE
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Credential | PH.D.
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Telephone | 310-477-8140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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