Provider Demographics
NPI:1063635282
Name:INDEPENDENCE COMMUNITY TREATMENT CLINIC
Entity Type:Organization
Organization Name:INDEPENDENCE COMMUNITY TREATMENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANZBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-776-1755
Mailing Address - Street 1:19231 VICTORY BLVD
Mailing Address - Street 2:SUITE 554
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 SIERRA CT
Practice Address - Street 2:SUITE C-8
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7607
Practice Address - Country:US
Practice Address - Phone:818-776-1755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70956FMedicaid