Provider Demographics
NPI:1881839033
Name:INDEPENDENCE COMMUNITY TREATMENT CLINIC
Entity Type:Organization
Organization Name:INDEPENDENCE COMMUNITY TREATMENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANZBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-776-1755
Mailing Address - Street 1:19231 VICTORY BLVD
Mailing Address - Street 2:SUITE 554
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6308
Mailing Address - Country:US
Mailing Address - Phone:818-776-1755
Mailing Address - Fax:818-776-1657
Practice Address - Street 1:45030 3RD ST E
Practice Address - Street 2:ROOM 09,10,15,16,17
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-2503
Practice Address - Country:US
Practice Address - Phone:818-776-1755
Practice Address - Fax:818-776-1657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001358261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA196856000Medicaid
CACMM70956FMedicaid