Healthcare Provider Details

I. General information

NPI: 1184541385
Provider Name (Legal Business Name): KULA DETOX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4417 CARLING DR
SAN DIEGO CA
92115-5527
US

IV. Provider business mailing address

2261 MARKET ST STE 24675
SAN FRANCISCO CA
94114-1612
US

V. Phone/Fax

Practice location:
  • Phone: 619-856-6569
  • Fax:
Mailing address:
  • Phone: 619-856-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SHANNAN WILSON
Title or Position: PRESIDENT
Credential:
Phone: 619-842-2240