MEDICARE: THIRD STREET TREATMENT PARTNERS LLC

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	251B00000X	Case Management Agency	190695	CA
2	324500000X	Substance Abuse Rehabilitation Facility	190695	CA

General Provider Information

NPI Number	:	1588943203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THIRD STREET TREATMENT PARTNERS LLC

Provider Business Mailing Address
First Line	:	4067 W 3RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-3120
Country	:	US
Telephone Number	:	818-635-9380
Fax Number	:	818-337-0365

Provider Business Practice Location Address
First Line	:	4067 W 3RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-3120
Country	:	US
Telephone Number	:	818-635-9380
Fax Number	:	818-337-0365

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	CHRISTOPHER BATHUM
Credential	:	PROGRAM ADMIN ADP
Telephone Number	:	818-635-9380

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/11/2011

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