Organization
RENEWAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLIOT LIEBHARD (ADMINISTRATOR)
(917) 374-4215
Entity
Organization
Contact information
Practice address
672 S LA FAYETTE PARK PL, LOS ANGELES, CA 91607
(917) 374-4215
Mailing address
4931 BLUEBELL AVE, LOS ANGELES, CA 91607
Taxonomy
Speciality
Code
Description
License number
State
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
—
Other
Enumeration date
10/04/2016
Last updated
10/04/2016
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