Provider Demographics
NPI:1376829432
Name:MC INTYRE HOUSE
Entity Type:Organization
Organization Name:MC INTYRE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:T
Authorized Official - Last Name:MARISTELA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:323-662-0855
Mailing Address - Street 1:544 N KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-6815
Mailing Address - Country:US
Mailing Address - Phone:323-662-0855
Mailing Address - Fax:323-662-0842
Practice Address - Street 1:544 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-6815
Practice Address - Country:US
Practice Address - Phone:323-662-0855
Practice Address - Fax:323-662-0842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190420AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility