Provider Demographics
NPI:1922131549
Name:L. A.SOUTH HEALTH SERVIES
Entity type:Organization
Organization Name:L. A.SOUTH HEALTH SERVIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCUTUVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:E
Authorized Official - Last Name:ETUK
Authorized Official - Suffix:
Authorized Official - Credentials:COUNSELOR
Authorized Official - Phone:323-751-0608
Mailing Address - Street 1:1704 W MANCHESTER AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-3034
Mailing Address - Country:US
Mailing Address - Phone:323-751-0608
Mailing Address - Fax:323-751-0375
Practice Address - Street 1:1704 W MANCHESTER AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3034
Practice Address - Country:US
Practice Address - Phone:323-751-0608
Practice Address - Fax:323-751-0375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190476AN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190476ANOtherDRUG REHABILITATION CLINI