Provider Demographics
NPI:1023376142
Name:BROADWAY TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:BROADWAY TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:LENNERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-655-0948
Mailing Address - Street 1:18582 BEACH BLVD STE 214
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2043
Mailing Address - Country:US
Mailing Address - Phone:714-655-0948
Mailing Address - Fax:
Practice Address - Street 1:18582 BEACH BLVD STE 214
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2043
Practice Address - Country:US
Practice Address - Phone:714-655-0948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility