MEDICARE: PROMISE TRANSITIONAL HOMES

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1538023940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROMISE TRANSITIONAL HOMES

Provider Business Mailing Address
First Line	:	1858 W 69TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-1823
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1858 W 69TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-1823
Country	:	US
Telephone Number	:	323-207-9940
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	TRACIA EKOLLO
Credential	:
Telephone Number	:	323-207-9940

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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Directions to “PROMISE TRANSITIONAL HOMES ” Practice Location

Language	Start Address	Practice Location

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