Basic Information
| Provider Information | |||||||||
| NPI: | 1134528805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CO. OF SAN LUIS OBISPO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAN LUIS OBISPO COUNTY DRUG AND ALCOHOL SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1523 LONGBRANCH AVE | ||||||||
| Address2: | |||||||||
| City: | GROVER BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934332508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054737080 | ||||||||
| FaxNumber: | 8054737188 | ||||||||
| Practice Location | |||||||||
| Address1: | 1523 LONGBRANCH AVE | ||||||||
| Address2: | |||||||||
| City: | GROVER BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934332508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054737080 | ||||||||
| FaxNumber: | 8054737188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2014 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | MADALYN | ||||||||
| AuthorizedOfficialMiddleName: | BETHANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8057047612 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M-R.A.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | P0602150905 | CA | Y | Agencies | Case Management |
No ID Information.