=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073844429
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STUDENT SPORTS ASSOCIATION SACRAMENTO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2010
-----------------------------------------------------
Last Update Date | 01/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8126 BELVEDERE AVE
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-870-0458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8126 BELVEDERE AVE
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-870-0458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. BRIAN MITCHELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-698-8687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------