=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750122966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELYSIAN HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 04/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7966 BEVERLY BLVD STE 103
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-892-6295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7966 BEVERLY BLVD STE 103
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-892-6295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JUSTIN WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-892-6295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------