Provider Demographics
NPI:1710693403
Name:CLIFFSIDE MALIBU 1
Entity Type:Organization
Organization Name:CLIFFSIDE MALIBU 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-579-1004
Mailing Address - Street 1:29160 HEATHERCLIFF RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-6306
Mailing Address - Country:US
Mailing Address - Phone:424-217-1052
Mailing Address - Fax:424-217-1052
Practice Address - Street 1:5480 HORIZON DR
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-3755
Practice Address - Country:US
Practice Address - Phone:424-217-1052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility