Healthcare Provider Details

I. General information

NPI: 1033028568
Provider Name (Legal Business Name): JOE AMBROSE SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5018 MARCONI AVE APT 151
CARMICHAEL CA
95608-4254
US

IV. Provider business mailing address

5018 MARCONI AVE APT 151
CARMICHAEL CA
95608-4254
US

V. Phone/Fax

Practice location:
  • Phone: 619-755-4552
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number26652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: