MEDICARE: TIKVA TREATMENT

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	324500000X	Substance Abuse Rehabilitation Facility	400009CP	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	400009CP	OTHER	CA	STATE OF CALIFORNIA DEPT OF HEALTH

General Provider Information

NPI Number	:	1770038663
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIKVA TREATMENT

Provider Business Mailing Address
First Line	:	2030 IDYLLWILD PL
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-9601
Country	:	US
Telephone Number	:	805-202-3440
Fax Number	:	888-510-9071

Provider Business Practice Location Address
First Line	:	2030 IDYLLWILD PL
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-9601
Country	:	US
Telephone Number	:	805-202-3440
Fax Number	:	888-510-9071

Authorized Official
Title or Position	:	CEO
Name	:	MR. ARI HIRT
Credential	:	MBA
Telephone Number	:	310-502-6991

Provider Enumeration Date	:	08/20/2016
Last Update Date	:	08/20/2016

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Directions to “TIKVA TREATMENT ” Practice Location

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