Provider Demographics
NPI:1003003542
Name:EMQ HOLLYGROVE
Entity Type:Organization
Organization Name:EMQ HOLLYGROVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARACOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-463-2119
Mailing Address - Street 1:815 N EL CENTRO AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-3805
Mailing Address - Country:US
Mailing Address - Phone:323-463-2119
Mailing Address - Fax:323-463-0619
Practice Address - Street 1:815 N EL CENTRO AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3805
Practice Address - Country:US
Practice Address - Phone:323-463-2119
Practice Address - Fax:323-463-0619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health