1730632159 NPI number — LIFESYNC RECOVERY AND DETOXIFICATION, LLC

Table of content: (NPI 1730632159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730632159 NPI number — LIFESYNC RECOVERY AND DETOXIFICATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESYNC RECOVERY AND DETOXIFICATION, LLC
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:
1730632159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 MURPHY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALIBU
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90265-4490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-951-6340
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28632 ROADSIDE DR
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
AGOURA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91301-6064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-951-6340
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BOOTH
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-951-6340

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  190920AP , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com