MEDICARE: THERON LEON CHILES

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

General Provider Information

NPI Number	:	1700054806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERON LEON CHILES

Provider Business Mailing Address
First Line	:	9100 S SEPULVEDA BLVD
Second Line	:	SUITE 105
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4814
Country	:	US
Telephone Number	:	310-644-3659
Fax Number	:

Provider Business Practice Location Address
First Line	:	9100 S SEPULVEDA BLVD
Second Line	:	SUITE 105
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4814
Country	:	US
Telephone Number	:	310-644-3659
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	07/12/2016

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Directions to “ THERON LEON CHILES ” Practice Location

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