Healthcare Provider Details

I. General information

NPI: 1821533696
Provider Name (Legal Business Name): SOUTH COUNTY ADDICTION TREATMENT SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 W AVENIDA SAN ANTONIO
SAN CLEMENTE CA
92672-4354
US

IV. Provider business mailing address

PO BOX 3699
SAN CLEMENTE CA
92674-3699
US

V. Phone/Fax

Practice location:
  • Phone: 916-607-9197
  • Fax: 949-424-0743
Mailing address:
  • Phone: 916-607-9197
  • Fax: 949-424-0743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberA82776
License Number StateCA

VIII. Authorized Official

Name: DAVID IAN DEYHIMY
Title or Position: CEO/DIRECTOR
Credential: M.D.
Phone: 916-607-9197