Provider Demographics
NPI:1285414573
Name:MITCHLOCK FOUNDATION
Entity type:Organization
Organization Name:MITCHLOCK FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-251-4116
Mailing Address - Street 1:10018 S VAN NESS AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-4145
Mailing Address - Country:US
Mailing Address - Phone:323-251-4116
Mailing Address - Fax:
Practice Address - Street 1:9061 S NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-2051
Practice Address - Country:US
Practice Address - Phone:323-251-4116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No177F00000XOther Service ProvidersLodging
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility