MEDICARE: INDEPENDENCE COMMUNITY TREATMENT CLINIC

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	261QC1500X	Community Health Clinic/Center	960001358	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396990685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE COMMUNITY TREATMENT CLINIC

Provider Business Mailing Address
First Line	:	19231 VICTORY BLVD
Second Line	:	SUITE 554
City	:	RESEDA
State	:	CA
Zip	:	91335-6308
Country	:	US
Telephone Number	:	818-776-1755
Fax Number	:	818-776-1657

Provider Business Practice Location Address
First Line	:	3200 E AVENUE J8
Second Line	:	ROOM 101,102,103,104,121,124
City	:	LANCASTER
State	:	CA
Zip	:	93535-5827
Country	:	US
Telephone Number	:	818-776-1755
Fax Number	:	818-776-1657

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	ALEX BRANZBURG
Credential	:
Telephone Number	:	818-776-1755

Provider Enumeration Date	:	12/01/2008
Last Update Date	:	12/11/2009

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