=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780118265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAZ CAPITAL INVESTMENTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2017
-----------------------------------------------------
Last Update Date | 06/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7966 BEVERLY BLVD STE 102
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-896-9431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7966 BEVERLY BLVD STE 102
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-896-9431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JUSTIN WELLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-896-9431
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 190945AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 190945AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------