=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790932242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPEN ARMS MENS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2008
-----------------------------------------------------
Last Update Date | 08/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4277 S WESTERN AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90062-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-755-2742
-----------------------------------------------------
Fax | 310-876-0533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8306 WILSHIRE BLVD STE 7024
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90211-2382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-755-2742
-----------------------------------------------------
Fax | 310-876-0533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | RHONDA LABOMME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-855-5656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 190518AN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------