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General NPI Number Information
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NPI Number | 1790924132
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Entity Type | Organization
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Legal Business Name | LIVING PROOF RECOVERY CENTER
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Dates
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Enumeration Date | 02/09/2009
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Last Update Date | 05/17/2013
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Provider Practice Location Address
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Address Line | 324 W FOOTHILL BLVD
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City | MONROVIA
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State | CA
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Zip | 91016-2149
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Country | US
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Telephone | 626-205-2518
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Fax | 626-446-5910
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Provider Business Mailing Address
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Address Line | PO BOX 2420
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City | MONROVIA
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State | CA
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Zip | 91017-6420
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Country | US
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Telephone | 626-205-2518
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Fax | 626-446-5910
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Authorized Official
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Title or Position | OWNER/DIRECTOR OF OPERATIONS
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Name | MR. GERALD M POOL
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Credential | LAADC, CADCII, S.A.P
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Telephone | 626-205-2518
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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 | 190316BP
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License Number State | CA
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