1366240301 NPI number — LEGACY VALLEY ADDICTION TREATMENT

Table of content: (NPI 1366240301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366240301 NPI number — LEGACY VALLEY ADDICTION TREATMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY VALLEY ADDICTION TREATMENT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366240301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12654 SEVENTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92395-9577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-912-5553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16519 VICTOR ST STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-3967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-305-9677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2025

Additional Information

Authorized Official

Authorized Official Last Name:
ABBOTT
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
760-912-5553

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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