Healthcare Provider Details

I. General information

NPI: 1255708855
Provider Name (Legal Business Name): BUPHANT SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 N. ELDORADO 11
STOCKTON CA
95202
US

IV. Provider business mailing address

1045 N. ELDORADO #11
STOCKTON CA
95202
US

V. Phone/Fax

Practice location:
  • Phone: 209-670-6799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberIMF 85548
License Number StateCA

VIII. Authorized Official

Name: MR. DAVID GRAYSON
Title or Position: CEO
Credential:
Phone: 209-670-6799