Provider Demographics
NPI:1063798965
Name:MALIBU CALIFORNIA MODEL DRUG TREATMENT CENTER,INC
Entity type:Organization
Organization Name:MALIBU CALIFORNIA MODEL DRUG TREATMENT CENTER,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHMELEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-585-0027
Mailing Address - Street 1:30101 AGOURA CT STE 103
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4301
Mailing Address - Country:US
Mailing Address - Phone:818-532-6243
Mailing Address - Fax:818-532-6244
Practice Address - Street 1:30101 AGOURA CT STE 103
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4301
Practice Address - Country:US
Practice Address - Phone:818-532-6243
Practice Address - Fax:818-532-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 276400000X
CA190729BP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility