Healthcare Provider Details

I. General information

NPI: 1679391908
Provider Name (Legal Business Name): JAMES CORBIN RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 YOSEMITE PKWY
MERCED CA
95340-5203
US

IV. Provider business mailing address

273 E 23RD ST
MERCED CA
95340-3950
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-6335
  • Fax:
Mailing address:
  • Phone: 209-261-9961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1575340824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: