Provider Demographics
NPI:1619426707
Name:5 RES DETOX LLC
Entity Type:Organization
Organization Name:5 RES DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEXIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-944-9468
Mailing Address - Street 1:10902 RIVERSIDE DR #B
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91682
Mailing Address - Country:US
Mailing Address - Phone:213-944-9468
Mailing Address - Fax:
Practice Address - Street 1:10902 RIVERSIDE DR #B
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91682
Practice Address - Country:US
Practice Address - Phone:213-944-9468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-29
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder