Provider Demographics
NPI:1033511548
Name:CIRCLE OF LIFE OUTPATIENT, INC.
Entity Type:Organization
Organization Name:CIRCLE OF LIFE OUTPATIENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VERKHOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-595-3450
Mailing Address - Street 1:2420 HERCULES DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-1634
Mailing Address - Country:US
Mailing Address - Phone:323-578-8546
Mailing Address - Fax:
Practice Address - Street 1:715 N RIDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3105
Practice Address - Country:US
Practice Address - Phone:323-578-8546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility