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General NPI Number Information
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NPI Number | 1932721099
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Entity Type | Organization
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Legal Business Name | MARIPOSA DETOX CENTER LLC
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Dates
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Enumeration Date | 05/12/2020
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 832 N MARIPOSA AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-3405
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Country | US
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Telephone | 561-563-6582
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Fax |
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Provider Business Mailing Address
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Address Line | 832 N MARIPOSA AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-3405
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Country | US
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Telephone | 561-563-6582
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | BRANDAN FREEMAN
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Credential |
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Telephone | 631-245-0911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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