Organization
INDEPENDENCE COMMUNITY TREATMENT CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ALEX BRANZBURG (PROGRAM DIRECTOR)
(818) 776-1755
Entity
Organization
Contact information
Practice address
39055 25TH ST W, ROOM426,427,428,429,430, PALMDALE, CA 93551-4164
(818) 776-1755
(818) 776-1657
Mailing address
19231 VICTORY BLVD, SUITE 554, RESEDA, CA 91335-6308
(818) 776-1755
(818) 776-1657
Taxonomy
Speciality
Code
Description
License number
State
261QC1500X
Community Health Clinic/Center
Primary
960001358
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
196856000
—
CA
05
—
CMM70956F
—
CA
Enumeration date
12/01/2008
Last updated
12/11/2009
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