Basic Information
| Provider Information | |||||||||
| NPI: | 1770967267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SECOND2NONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32619 VIA PERALES | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925928148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515871073 | ||||||||
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| Practice Location | |||||||||
| Address1: | 32619 VIA PERALES | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925928148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515871073 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | DUDEK | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | KATHRYN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9514611800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | CADC-II, ICADC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1202970615 | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.