Provider Demographics
NPI:1275003543
Name:ACOSTA, LESSA ILEANA
Entity Type:Individual
Prefix:
First Name:LESSA
Middle Name:ILEANA
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30500 ARRASTRE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:CA
Mailing Address - Zip Code:93510-2160
Mailing Address - Country:US
Mailing Address - Phone:661-223-8751
Mailing Address - Fax:661-269-0427
Practice Address - Street 1:30500 ARRASTRE CANYON RD.
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:CA
Practice Address - Zip Code:93510
Practice Address - Country:US
Practice Address - Phone:661-223-8751
Practice Address - Fax:661-269-0427
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190001AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316397938OtherANTELOPE VALLEY REHABILITATION CENTERS RESIDENTIAL