Provider Demographics
NPI:1760053391
Name:22703 SYLVAN STREET DETOX LLC
Entity Type:Organization
Organization Name:22703 SYLVAN STREET DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KEANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-229-2061
Mailing Address - Street 1:22703 SYLVAN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-1625
Mailing Address - Country:US
Mailing Address - Phone:424-229-2061
Mailing Address - Fax:
Practice Address - Street 1:22703 SYLVAN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-1625
Practice Address - Country:US
Practice Address - Phone:828-367-8727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility