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General NPI Number Information
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NPI Number | 1043768807
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Entity Type | Organization
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Legal Business Name | SACRED SPACE HEALING & RETREAT CENTER INTERNATIONAL, INC.
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Dates
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Enumeration Date | 09/21/2016
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Last Update Date | 09/21/2016
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Provider Practice Location Address
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Address Line | 627 CHERRY CREEK RD. BOX 311
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City | CLOVERDALE
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State | CA
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Zip | 95425
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Country | US
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Telephone | 707-894-0063
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Fax |
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Provider Business Mailing Address
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Address Line | 627 CHERRY CREEK RD. BOX 311
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City | CLOVERDALE
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State | CA
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Zip | 95425
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Country | US
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Telephone | 707-894-0063
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Fax | 800-914-6360
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Authorized Official
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Title or Position | CEO / PRESIDENT
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Name | MR. ANUSHA AMEN-RA
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Credential | C.N.C.
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Telephone | 707-894-0063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 490039AP
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License Number State | CA
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