Basic Information
| Provider Information | |||||||||
| NPI: | 1518024389 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRUG ABUSE ALTERNATIVES CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2403 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075712233 | ||||||||
| FaxNumber: | 7075712238 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075712233 | ||||||||
| FaxNumber: | 7075712238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHALLIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CENTER POINT VICE PRESIDENT, DAAC M | ||||||||
| AuthorizedOfficialTelephone: | 7075712233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 490009BN | CA | N | Agencies | Community/Behavioral Health | 324500000X | 490009RN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 490009BN | 01 | CA | DADP CERTIFICATION | OTHER | 49490700 | 01 | CA | MEDICAL | OTHER |