=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730722828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA VITAE RECOVERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2019
-----------------------------------------------------
Last Update Date | 10/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5985 TOPANGA CANYON BLVD
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-925-5985
-----------------------------------------------------
Fax | 818-647-6500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4942 VINELAND AVE STE R
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91601-5637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-422-3442
-----------------------------------------------------
Fax | 818-647-6500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC DIRECTOR
-----------------------------------------------------
Name | MR. ALLEN YADEGAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-422-3442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------