Organization
REVIVE DETOX
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MATTHEW CONLEY (PROGRAM DIRECTOR)
(818) 462-3824
Entity
Organization
Contact information
Practice address
360 N VISTA ST, LOS ANGELES, CA 90036-5739
(818) 462-3824
Mailing address
360 N VISTA ST, LOS ANGELES, CA 90036-5739
(818) 462-3824
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
190836AP
CA
Other
Enumeration date
03/02/2015
Last updated
03/02/2015
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