Provider Demographics
NPI:1780045302
Name:SG DETOX 5156 LLC
Entity Type:Organization
Organization Name:SG DETOX 5156 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TELANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-272-1860
Mailing Address - Street 1:2640 LINCOLN BLVD
Mailing Address - Street 2:#8
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4620
Mailing Address - Country:US
Mailing Address - Phone:424-272-1860
Mailing Address - Fax:
Practice Address - Street 1:5156 BASCULE AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-3447
Practice Address - Country:US
Practice Address - Phone:818-456-4658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility