MEDICARE: LOS ANGELES YOUTH NETWORK

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	198208596	CA

General Provider Information

NPI Number	:	1689119380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOS ANGELES YOUTH NETWORK

Provider Business Mailing Address
First Line	:	1754 TAFT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-5705
Country	:	US
Telephone Number	:	323-366-2450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1719 TAFT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-5704
Country	:	US
Telephone Number	:	323-957-7757
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MARK SUPPER
Credential	:
Telephone Number	:	323-467-8466

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

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