Healthcare Provider Details

I. General information

NPI: 1760937205
Provider Name (Legal Business Name): MICHAEL EDWARD KUDRNA CATC-III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4558
US

IV. Provider business mailing address

2180 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4558
US

V. Phone/Fax

Practice location:
  • Phone: 805-788-2159
  • Fax: 805-781-4866
Mailing address:
  • Phone: 805-788-2159
  • Fax: 805-781-4866

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: