MEDICARE: SOLACE, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1386342400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLACE, INC

Provider Business Mailing Address
First Line	:	11240 MAGNOLIA BLVD STE 204
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91601-3975
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11240 MAGNOLIA BLVD STE 204
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91601-3975
Country	:	US
Telephone Number	:	818-359-9408
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	HUGO MAURICIO SOTO
Credential	:
Telephone Number	:	818-359-9408

Provider Enumeration Date	:	02/17/2023
Last Update Date	:	08/28/2024

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Directions to “SOLACE, INC ” Practice Location

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