Healthcare Provider Details

I. General information

NPI: 1619793957
Provider Name (Legal Business Name): EMMETT JUSTIN HULL CADCII
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 N MOUNTAIN AVE STE A-C
UPLAND CA
91786-3659
US

IV. Provider business mailing address

934 N MOUNTAIN AVE STE A-C
UPLAND CA
91786-3659
US

V. Phone/Fax

Practice location:
  • Phone: 909-949-4667
  • Fax:
Mailing address:
  • Phone: 909-949-4667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA059270121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: