Healthcare Provider Details

I. General information

NPI: 1659940658
Provider Name (Legal Business Name): CHRISTIAN CHARLES FORD-RODRIGUEZ CATC-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 30TH ST STE 100
SANTA MONICA CA
90405-3051
US

IV. Provider business mailing address

2644 30TH ST STE 100
SANTA MONICA CA
90405-3051
US

V. Phone/Fax

Practice location:
  • Phone: 310-314-6200
  • Fax: 310-450-2024
Mailing address:
  • Phone: 310-314-6200
  • Fax: 310-450-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14632-RAC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: