Provider Demographics
NPI:1356659023
Name:1775 SUMMITRIDGE DRIVE, LLC
Entity Type:Organization
Organization Name:1775 SUMMITRIDGE DRIVE, LLC
Other - Org Name:ONE80 CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SHOHET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-588-4180
Mailing Address - Street 1:1775 SUMMITRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-1607
Mailing Address - Country:US
Mailing Address - Phone:888-588-4180
Mailing Address - Fax:888-588-4080
Practice Address - Street 1:1775 SUMMITRIDGE DR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-1607
Practice Address - Country:US
Practice Address - Phone:888-588-4180
Practice Address - Fax:888-588-4080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility