MEDICARE: DUAL DIAGNOSIS ASSESMENT AND TREATMENT CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	55000015	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CMM71075F	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1093701534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUAL DIAGNOSIS ASSESMENT AND TREATMENT CENTER INC

Provider Business Mailing Address
First Line	:	19300 RINALDI STREET
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91327-9998
Country	:	US
Telephone Number	:	818-804-4043
Fax Number	:	818-804-4047

Provider Business Practice Location Address
First Line	:	19300 RINALDI ST
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91326-1651
Country	:	US
Telephone Number	:	310-628-9512
Fax Number	:	818-831-3416

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. EDNA ELIZABETH MILLER
Credential	:
Telephone Number	:	818-804-4043

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	01/23/2008

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