Healthcare Provider Details

I. General information

NPI: 1144745969
Provider Name (Legal Business Name): MARK EDWIN SKORICH CADC1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 N FAIR OAKS AVE
PASADENA CA
91103-1642
US

IV. Provider business mailing address

1680 N FAIR OAKS AVE
PASADENA CA
91103-1642
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-0884
  • Fax: 626-798-6970
Mailing address:
  • Phone: 626-798-0884
  • Fax: 626-798-6970

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: