Healthcare Provider Details

I. General information

NPI: 1396150074
Provider Name (Legal Business Name): DIVERSIFIED INTERVENTION GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 06/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 SEQUOIA ST
MORRO BAY CA
93442-1409
US

IV. Provider business mailing address

309 SEQUOIA ST
MORRO BAY CA
93442-1409
US

V. Phone/Fax

Practice location:
  • Phone: 805-602-0681
  • Fax:
Mailing address:
  • Phone: 805-602-0681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD ALLEN SALAN
Title or Position: FOUNDING DIRECTOR
Credential:
Phone: 805-602-0681