Provider Demographics
NPI:1821625138
Name:ASC TREATMENT GROUP
Entity Type:Organization
Organization Name:ASC TREATMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:323-318-2520
Mailing Address - Street 1:2457 ENDICOTT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-3047
Mailing Address - Country:US
Mailing Address - Phone:323-227-5252
Mailing Address - Fax:323-227-9032
Practice Address - Street 1:2457 ENDICOTT ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-3098
Practice Address - Country:US
Practice Address - Phone:323-227-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility