Healthcare Provider Details

I. General information

NPI: 1417076563
Provider Name (Legal Business Name): ROBERT B DIBBLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 E LINE ST
BISHOP CA
93514-3566
US

IV. Provider business mailing address

375 E LINE ST
BISHOP CA
93514-3566
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-4357
  • Fax: 760-873-7446
Mailing address:
  • Phone: 760-873-4357
  • Fax: 760-873-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number140001AP
License Number StateCA

VIII. Authorized Official

Name: DR. ROBERT BAILEY DIBBLE
Title or Position: DIRECTOR
Credential: PH.D. PSYCHOLOGIST
Phone: 760-873-4357