Provider Demographics
NPI:1447559547
Name:KLEAN W. HOLLYWOOD
Entity Type:Organization
Organization Name:KLEAN W. HOLLYWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-492-9824
Mailing Address - Street 1:8543 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:W HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4150
Mailing Address - Country:US
Mailing Address - Phone:310-492-9824
Mailing Address - Fax:
Practice Address - Street 1:852 HILLDALE AVE
Practice Address - Street 2:,852 1/2, 854 HILLDALE AVE
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4915
Practice Address - Country:US
Practice Address - Phone:310-492-9824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190692EP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility