=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730758491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JJLT HOLDINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2021
-----------------------------------------------------
Last Update Date | 09/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 LAKE ST
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92648-5928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-467-4324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16168 BEACH BLVD # 201C
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-467-4324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTANT
-----------------------------------------------------
Name | REBECCA HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-467-4324
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 276400000X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------