MEDICARE: CIRCLE OF LIFE OUTPATIENT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1033511548
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CIRCLE OF LIFE OUTPATIENT, INC.

Provider Business Mailing Address
First Line	:	2420 HERCULES DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-1634
Country	:	US
Telephone Number	:	323-578-8546
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 N RIDGEWOOD PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90038-3105
Country	:	US
Telephone Number	:	323-578-8546
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. MARINA VERKHOVSKY
Credential	:
Telephone Number	:	213-595-3450

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	09/16/2014

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