Provider Demographics
NPI:1689489023
Name:WELLNESS DETOX LA LLC
Entity type:Organization
Organization Name:WELLNESS DETOX LA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:PETRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-440-3200
Mailing Address - Street 1:621 NW 53RD ST STE 370
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-8241
Mailing Address - Country:US
Mailing Address - Phone:978-440-3200
Mailing Address - Fax:
Practice Address - Street 1:631 E PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-4569
Practice Address - Country:US
Practice Address - Phone:909-589-6783
Practice Address - Fax:949-606-0488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility