Healthcare Provider Details

I. General information

NPI: 1740972702
Provider Name (Legal Business Name): MICHAEL JAMES OFFICER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2980 CEDAR ST
SAN DIEGO CA
92102-1599
US

IV. Provider business mailing address

2980 CEDAR ST
SAN DIEGO CA
92102-1599
US

V. Phone/Fax

Practice location:
  • Phone: 619-239-7370
  • Fax:
Mailing address:
  • Phone: 619-239-7370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1468910522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: