MEDICARE: HOLLYWOOD RECOVERY TREATMENT CENTER

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	251S00000X	Community/Behavioral Health Agency	6895	CA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6895	OTHER	CA	PROVIDER NUMBER

General Provider Information

NPI Number	:	1518181379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLYWOOD RECOVERY TREATMENT CENTER

Provider Business Mailing Address
First Line	:	12500 RIVERSIDE DR STE 211
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91607-3436
Country	:	US
Telephone Number	:	818-980-0849
Fax Number	:	818-980-0859

Provider Business Practice Location Address
First Line	:	12500 RIVERSIDE DR STE 211
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91607-3436
Country	:	US
Telephone Number	:	818-980-0849
Fax Number	:	818-980-0859

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MARTIN AGUILAR
Credential	:
Telephone Number	:	818-980-0849

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/31/2013

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Directions to “HOLLYWOOD RECOVERY TREATMENT CENTER ” Practice Location

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