MEDICARE: HOLLYWOOD LUXURY REHAB

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1932978723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLYWOOD LUXURY REHAB

Provider Business Mailing Address
First Line	:	7633 TEESDALE AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-2139
Country	:	US
Telephone Number	:	323-395-7772
Fax Number	:

Provider Business Practice Location Address
First Line	:	6425 WEIDLAKE DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-2277
Country	:	US
Telephone Number	:	323-395-7772
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	STEPAN AJEMYAN
Credential	:
Telephone Number	:	323-395-7772

Provider Enumeration Date	:	12/21/2023
Last Update Date	:	12/21/2023

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Directions to “HOLLYWOOD LUXURY REHAB ” Practice Location

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