Organization11821 Foothill BlvdCounselorBehavioral Health & Social Service ProvidersPractice Address5436 S. Broadway, Los Angeles, CA 90037(818) 694-7206PECOS EnrollmentBased on the most recent information from CMS, provider 11821 Foothill Blvd does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records today at 9:43 AM.Profile DetailsProvider ID1164767356Provider TypeOrganizationFull Name11821 Foothill BlvdSubpartNoEnumeration Date11/29/2012Last Updated11/29/2012Contact InformationPractice LocationPractice Address5436 S. Broadway, Los Angeles, CA 90037Phone(818) 694-7206FaxUnlisted FaxMailing LocationMailing Address11821 Foothill Blvd # K35, Lake View Terrace, CA 91342-7200Phone(818) 694-7206FaxUnlisted FaxAuthorized OfficialNameFortune, Derrick Bradley (Counselor)Phone(818) 694-7206Provider TaxonomiesCodeDescriptionLicenseCode101YA0400XPrimaryDescriptionCounselorBehavioral Health & Social Service ProvidersLicenseUnlisted Issuer