Healthcare Provider Details

I. General information

NPI: 1124394549
Provider Name (Legal Business Name): DUAL DIAGNOSIS TREATMENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CALLE REAL
SAN CLEMENTE CA
92673-2624
US

IV. Provider business mailing address

PO BOX 5915
SAN CLEMENTE CA
92674-5915
US

V. Phone/Fax

Practice location:
  • Phone: 302-354-9310
  • Fax:
Mailing address:
  • Phone: 949-625-0376
  • Fax: 949-390-9899

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: TONMOY SHARMA
Title or Position: CEO
Credential:
Phone: 610-416-1205