MEDICARE: DESIRE 4 CHANGE LIVING IOP

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1548708365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESIRE 4 CHANGE LIVING IOP

Provider Business Mailing Address
First Line	:	17019 SAN JOSE ST
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-6238
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17019 SAN JOSE ST
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-6238
Country	:	US
Telephone Number	:	310-345-9618
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE PROGRAM DIRECTOR
Name	:	MS. KIMBERLEE SAFFORE
Credential	:
Telephone Number	:	310-345-9618

Provider Enumeration Date	:	02/01/2017
Last Update Date	:	04/06/2017

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