Provider Demographics
NPI:1487728184
Name:HOLLYWOOD
Entity type:Organization
Organization Name:HOLLYWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ARPI
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDONIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-960-1701
Mailing Address - Street 1:5300 SANTA MONICA BLVD STE 317
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1259
Mailing Address - Country:US
Mailing Address - Phone:323-960-1701
Mailing Address - Fax:
Practice Address - Street 1:5300 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029
Practice Address - Country:US
Practice Address - Phone:323-464-2066
Practice Address - Fax:323-464-0629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000632261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
8853732Medicare UPIN