Healthcare Provider Details

I. General information

NPI: 1619094984
Provider Name (Legal Business Name): ICBHS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 W STATE ST STE. 102
EL CENTRO CA
92243-2845
US

IV. Provider business mailing address

1295 W STATE ST STE. 102
EL CENTRO CA
92243-2845
US

V. Phone/Fax

Practice location:
  • Phone: 760-353-0763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GARY GARRISON
Title or Position: SUBSTANCE AUBSE COUNSELOR II
Credential:
Phone: 760-353-0763