MEDICARE: IRIS HEALING CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	261QM0850X	Adult Mental Health Clinic/Center
3	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1144734922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IRIS HEALING CENTER LLC

Provider Business Mailing Address
First Line	:	20300 VENTURA BLVD STE 300
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-0901
Country	:	US
Telephone Number	:	323-449-0016
Fax Number	:	818-301-1940

Provider Business Practice Location Address
First Line	:	20300 VENTURA BLVD STE 300
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-0901
Country	:	US
Telephone Number	:	323-449-0016
Fax Number	:	323-449-0016

Authorized Official
Title or Position	:	CEO
Name	:	DR. ELENA KAPUSTINA
Credential	:	PSYD
Telephone Number	:	323-449-0016

Provider Enumeration Date	:	11/30/2017
Last Update Date	:	07/02/2022

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