Provider Demographics
NPI:1144734922
Name:IRIS HEALING CENTER LLC
Entity type:Organization
Organization Name:IRIS HEALING CENTER 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 1:20300 VENTURA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-0901
Mailing Address - Country:US
Mailing Address - Phone:323-449-0016
Mailing Address - Fax:818-301-1940
Practice Address - Street 1:20300 VENTURA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-0901
Practice Address - Country:US
Practice Address - Phone:323-449-0016
Practice Address - Fax:323-449-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251B00000XAgenciesCase Management
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health