Healthcare Provider Details

I. General information

NPI: 1972019362
Provider Name (Legal Business Name): GEORGE EDGAR KRUSE IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501-4413
US

IV. Provider business mailing address

2245 PARKWOOD BLVD
EUREKA CA
95503-7042
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-2990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI07300317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: