| Organization Name: | INDEPENDENCE COMMUNITY TREATMENT CLINIC |
| NPI Number: | 1134366115 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ALEX BRANZBURG (PROGRAM DIRECTOR) |
| Mailing Address: | 10833 E Avenue R Room 118, 119, 217 Littlerock |
| State: | CA US |
| Postal Code: | 935434106 |
| Phone Number: | 8187761755 |
| Fax Number: | |
| NPI Enumeration Date: | 01/14/2009 |
| NPI Last Update Date: | 12/18/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QC1500X |
| License Number: | 960001358 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Community Health |
| Taxonomy Definition: | |