MEDICARE: CALIFORNIA IOP LLC

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1346089943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA IOP LLC

Provider Business Mailing Address
First Line	:	1402 W PICO AVE STE A50
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-1377
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 W PICO AVE STE A50
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-1377
Country	:	US
Telephone Number	:	866-986-6217
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS
Name	:	DANIELLE BOLDUC
Credential	:
Telephone Number	:	866-986-6217

Provider Enumeration Date	:	05/22/2024
Last Update Date	:	05/22/2024

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