Provider Demographics
NPI:1295144921
Name:POLARIS TEEN CENTER, LLC
Entity type:Organization
Organization Name:POLARIS TEEN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ARI
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-616-8650
Mailing Address - Street 1:4981 AMIGO AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4505
Mailing Address - Country:US
Mailing Address - Phone:818-616-8650
Mailing Address - Fax:
Practice Address - Street 1:4981 AMIGO AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4505
Practice Address - Country:US
Practice Address - Phone:818-616-8650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-06
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA198208336322D00000X, 3245S0500X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children