Healthcare Provider Details

I. General information

NPI: 1184847170
Provider Name (Legal Business Name): KENNETH DWAYNE HUGHES CAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W HOSPITAL RD
FRENCH CAMP CA
95231
US

IV. Provider business mailing address

2107 STEWART ST
STOCKTON CA
95205-3227
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-6857
  • Fax: 209-468-6739
Mailing address:
  • Phone: 209-469-3918
  • 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:
Title or Position:
Credential:
Phone: