Provider Demographics
NPI:1578103214
Name:LA DETOX LLC
Entity Type:Organization
Organization Name:LA DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-374-4215
Mailing Address - Street 1:4901 AMIGO AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4505
Mailing Address - Country:US
Mailing Address - Phone:917-374-4215
Mailing Address - Fax:
Practice Address - Street 1:4901 AMIGO AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4505
Practice Address - Country:US
Practice Address - Phone:917-374-4215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility