Healthcare Provider Details

I. General information

NPI: 1548770704
Provider Name (Legal Business Name): OPIOID & ALCOHOL ADDICTION CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4928 109TH ST SW
LAKEWOOD WA
98499-3731
US

IV. Provider business mailing address

PO BOX 6015
FEDERAL WAY WA
98063-6015
US

V. Phone/Fax

Practice location:
  • Phone: 253-332-2958
  • Fax:
Mailing address:
  • Phone: 253-332-2958
  • Fax: 253-838-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. BOPHA KREUK
Title or Position: OWNER
Credential:
Phone: 253-632-6348