1811200439 NPI number — NIRVANA DRUG AND ALCOHOL INSTITUTE

Table of content: (NPI 1811200439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811200439 NPI number — NIRVANA DRUG AND ALCOHOL INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIRVANA DRUG AND ALCOHOL INSTITUTE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811200439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 KANSAS AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95351-1596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-579-1151
Provider Business Mailing Address Fax Number:
209-579-9605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1028 RENO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95351-1127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-579-1103
Provider Business Practice Location Address Fax Number:
209-578-1085
Provider Enumeration Date:
07/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HELDING
Authorized Official First Name:
DANE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
209-579-1151

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  50009EN , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500009EN . This is a "DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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