=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003189614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERIM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2012
-----------------------------------------------------
Last Update Date | 02/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 PEARL ST INTERIM INC
-----------------------------------------------------
City | MONTEREY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93940-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-649-4522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 DELA VINA AVE APT 30
-----------------------------------------------------
City | MONTEREY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93940-3962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-562-7800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | WELLNESS RECOVERY COORDINATOR
-----------------------------------------------------
Name | KEVIN GAST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 660-562-7800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------