Provider Demographics
NPI:1861945560
Name:IRIS HEALING RETREAT LLC
Entity type:Organization
Organization Name:IRIS HEALING RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPUSTINA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:323-449-0016
Mailing Address - Street 1:23033 OSTRONIC DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6143
Mailing Address - Country:US
Mailing Address - Phone:818-436-2646
Mailing Address - Fax:818-301-1940
Practice Address - Street 1:5663 JUMILLA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6910
Practice Address - Country:US
Practice Address - Phone:323-449-0016
Practice Address - Fax:818-301-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility