Provider Demographics
NPI:1962657643
Name:CENTURY REGIONAL DETENTION FACILITY
Entity type:Organization
Organization Name:CENTURY REGIONAL DETENTION FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGY INTERN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:818-255-8254
Mailing Address - Street 1:6610 RIVERTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2209
Mailing Address - Country:US
Mailing Address - Phone:818-255-8254
Mailing Address - Fax:
Practice Address - Street 1:6610 RIVERTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2209
Practice Address - Country:US
Practice Address - Phone:818-255-8254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit