Basic Information
| Provider Information | |||||||||
| NPI: | 1043731987 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANOTHER ROAD DETOX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 SOUTH M STREET | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057360357 | ||||||||
| FaxNumber: | 8669299350 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 SOUTH M STREET | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057360357 | ||||||||
| FaxNumber: | 8669299350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2017 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLORES | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF TREATMENT | ||||||||
| AuthorizedOfficialTelephone: | 8052663747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CADTP/CAODC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
No ID Information.