Healthcare Provider Details

I. General information

NPI: 1508315250
Provider Name (Legal Business Name): CHANING TIDES TREATMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 SPERRY AVE SUITE 18
VENTURA CA
93003-7408
US

IV. Provider business mailing address

2021 SPERRY AVE SUITE 18
VENTURA CA
93003-7408
US

V. Phone/Fax

Practice location:
  • Phone: 844-883-3869
  • Fax: 805-624-5311
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA IACULLO
Title or Position: BILLING
Credential:
Phone: 954-415-8781