Provider Demographics
NPI:1275739401
Name:EMQ HOLLYGROVE
Entity Type:Organization
Organization Name:EMQ HOLLYGROVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DAY REHABILITATION SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DERIC
Authorized Official - Middle Name:MARTEZ
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:BA MHRS
Authorized Official - Phone:323-463-2119
Mailing Address - Street 1:950 S WESTMORELAND AVE
Mailing Address - Street 2:APT. 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-5669
Mailing Address - Country:US
Mailing Address - Phone:213-252-8577
Mailing Address - Fax:
Practice Address - Street 1:815 N EL CENTRO AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3805
Practice Address - Country:US
Practice Address - Phone:323-463-2119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA322D00000X322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children