Healthcare Provider Details

I. General information

NPI: 1962542274
Provider Name (Legal Business Name): PRINCIPLES INC (DBA) IMPACT DRUG & ALCOHOL TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
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 Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190094AN
License Number StateCA

VIII. Authorized Official

Name: MARK PAQUET
Title or Position: ADMISSIONS DIRECTOR
Credential: MBA, CAADE
Phone: 626-798-0884