Provider Demographics
NPI:1730537754
Name:BRENTWOOD - EATING DISORDER CENTER OF CALIFORNIA, LLC
Entity type:Organization
Organization Name:BRENTWOOD - EATING DISORDER CENTER OF CALIFORNIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-663-1876
Mailing Address - Street 1:6100 SW 76TH ST STE 208
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5002
Mailing Address - Country:US
Mailing Address - Phone:305-663-1876
Mailing Address - Fax:786-359-4485
Practice Address - Street 1:520 S SEPULVEDA BLVD STE 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3536
Practice Address - Country:US
Practice Address - Phone:310-472-3728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)