MEDICARE: INTEGRITY TREATMENT PROGRAM, 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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1619333002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRITY TREATMENT PROGRAM, LLC

Provider Business Mailing Address
First Line	:	12301 WILSHIRE BLVD STE 206
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1000
Country	:	US
Telephone Number	:	310-294-9030
Fax Number	:

Provider Business Practice Location Address
First Line	:	12301 WILSHIRE BLVD STE 206
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1000
Country	:	US
Telephone Number	:	310-294-9030
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	YESHAIA BLAKENEY
Credential	:
Telephone Number	:	310-294-9030

Provider Enumeration Date	:	01/14/2016
Last Update Date	:	05/07/2021

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