Provider Demographics
NPI:1568280691
Name:HOLLYCARE RECOVERY, INC.
Entity type:Organization
Organization Name:HOLLYCARE RECOVERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHUDAVERDYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-304-4138
Mailing Address - Street 1:14242 VENTURA BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14242 VENTURA BLVD STE 235
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2757
Practice Address - Country:US
Practice Address - Phone:323-304-4138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder