MEDICARE: STUDIO 12

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	190361AN	CA

General Provider Information

NPI Number	:	1144422817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STUDIO 12

Provider Business Mailing Address
First Line	:	12406 MAGNOLIA BLVD
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-2415
Country	:	US
Telephone Number	:	818-761-7374
Fax Number	:	818-761-7377

Provider Business Practice Location Address
First Line	:	12406 MAGNOLIA BLVD
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-2415
Country	:	US
Telephone Number	:	818-761-7374
Fax Number	:	818-761-7377

Authorized Official
Title or Position	:	CEO
Name	:	MR. ALAN W. FISKE
Credential	:
Telephone Number	:	818-761-7374

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	08/22/2020

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Directions to “STUDIO 12 ” Practice Location

Language	Start Address	Practice Location

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