1912738618 NPI number — ADDICTION CHANGE EXPERTS (ACE) MEDICAL INC

Table of content: (NPI 1912738618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912738618 NPI number — ADDICTION CHANGE EXPERTS (ACE) MEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADDICTION CHANGE EXPERTS (ACE) MEDICAL INC
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:
1912738618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
595 SAND DOLLAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA SELVA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95076-1815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-356-7136
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ADDICTION CHANGE EXPERTS (ACE) MEDICAL INC
Provider Second Line Business Practice Location Address:
5610 SCOTTS VALLEY DR STE B
Provider Business Practice Location Address City Name:
SCOTTS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-337-6383
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2024

Additional Information

Authorized Official

Authorized Official Last Name:
SANTILLANO
Authorized Official First Name:
EUGENE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CEO/ PRESIDENT
Authorized Official Telephone Number:
408-337-6383

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1619967007 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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