| Organization Name: | INDEPENDENCE COMMUNITY TREATMENT CLINIC |
| NPI Number: | 1417192550 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ALEX BRANZBURG (PROGRAM DIRECTOR) |
| Mailing Address: | 6040 W Avenue L Room423,v3, Agi Quartz Hill |
| State: | CA US |
| Postal Code: | 935364501 |
| Phone Number: | 8187761755 |
| Fax Number: | 8187761657 |
| NPI Enumeration Date: | 12/03/2008 |
| NPI Last Update Date: | 12/11/2009 |
| 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: | |