Basic Information
| Provider Information | |||||||||
| NPI: | 1063623593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRUG ABUSE ALTERNATIVES CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OUTPATIENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2403 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075443295 | ||||||||
| FaxNumber: | 7075449011 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075443295 | ||||||||
| FaxNumber: | 7075449011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHALLIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CENTER POINT VICE PRESIDENT, DAAC | ||||||||
| AuthorizedOfficialTelephone: | 4155262943 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DRUG ABUSE ALTERNATIVES CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.