Provider Demographics
NPI:1730632159
Name:LIFESYNC RECOVERY AND DETOXIFICATION, LLC
Entity type:Organization
Organization Name:LIFESYNC RECOVERY AND DETOXIFICATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-951-6340
Mailing Address - Street 1:6035 MURPHY WAY
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4490
Mailing Address - Country:US
Mailing Address - Phone:310-951-6340
Mailing Address - Fax:
Practice Address - Street 1:28632 ROADSIDE DR
Practice Address - Street 2:SUITE 235
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-6064
Practice Address - Country:US
Practice Address - Phone:310-951-6340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190920AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility