Provider Demographics
NPI:1083101661
Name:LA FUENTE HOLLYWOOD TREATMENT CENTER LLC
Entity type:Organization
Organization Name:LA FUENTE HOLLYWOOD TREATMENT CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-464-2947
Mailing Address - Street 1:5718 FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-8516
Mailing Address - Country:US
Mailing Address - Phone:323-464-2947
Mailing Address - Fax:
Practice Address - Street 1:1601 N GOWER ST # 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-7596
Practice Address - Country:US
Practice Address - Phone:323-464-2947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA FUENTE HOLLYWOOD TREATMENT CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility