Provider Demographics
NPI:1275124737
Name:MINDFUL LIVING CENTER CALIFORNIA LLC
Entity Type:Organization
Organization Name:MINDFUL LIVING CENTER CALIFORNIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:THARASRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-419-3869
Mailing Address - Street 1:900 PACIFIC COAST HWY APT 105
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4859
Mailing Address - Country:US
Mailing Address - Phone:323-419-3869
Mailing Address - Fax:
Practice Address - Street 1:714 W OLYMPIC BLVD STE 614
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1485
Practice Address - Country:US
Practice Address - Phone:213-510-6150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health