Provider Demographics
NPI:1386024115
Name:MIRACLE MILE COMMUNITY PRACTICE
Entity type:Organization
Organization Name:MIRACLE MILE COMMUNITY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:323-936-3965
Mailing Address - Street 1:7461 BEVERLY BLVD STE 405
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2774
Mailing Address - Country:US
Mailing Address - Phone:323-939-6355
Mailing Address - Fax:
Practice Address - Street 1:7461 BEVERLY BLVD STE 405
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2774
Practice Address - Country:US
Practice Address - Phone:323-939-6355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-07
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS15899251S00000X
CA52614251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health