Healthcare Provider Details

I. General information

NPI: 1639798564
Provider Name (Legal Business Name): BRITAIN KALOB DAVIS CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 35
FORTUNA CA
95540-0035
US

IV. Provider business mailing address

PO BOX 35
FORTUNA CA
95540-0035
US

V. Phone/Fax

Practice location:
  • Phone: 707-721-5592
  • Fax:
Mailing address:
  • Phone: 707-721-5592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: