Provider Demographics
NPI:1528201498
Name:MALIBU LIGHTHOUSE TREATMENT CENTERS
Entity Type:Organization
Organization Name:MALIBU LIGHTHOUSE TREATMENT CENTERS
Other - Org Name:AVALON RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLAIMS ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-488-5159
Mailing Address - Street 1:12517 YERBA BUENA RD
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-2107
Mailing Address - Country:US
Mailing Address - Phone:310-457-8067
Mailing Address - Fax:
Practice Address - Street 1:12517 YERBA BUENA RD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2107
Practice Address - Country:US
Practice Address - Phone:310-457-8067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MALIBU LIGHTHOUSE TREATMENT CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190612AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility