Provider Demographics
NPI:1720707987
Name:HILLSIDES
Entity Type:Organization
Organization Name:HILLSIDES
Other - Org Name:HILLSIDES STRTP LA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LSCW
Authorized Official - Phone:323-254-2274
Mailing Address - Street 1:940 N AVENUE 65
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1542
Mailing Address - Country:US
Mailing Address - Phone:323-254-2274
Mailing Address - Fax:
Practice Address - Street 1:940 N AVENUE 65
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1542
Practice Address - Country:US
Practice Address - Phone:323-254-2274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health