=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154410652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA DIVERSION INTERVENTION FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 07/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1095 N MAIN ST SUITE B
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92867-5476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-633-0502
-----------------------------------------------------
Fax | 714-633-9249
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1095 N MAIN ST SUITE B
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92867-5476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-633-0502
-----------------------------------------------------
Fax | 714-633-9249
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | MR. HARRY K. MIYAJI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-633-0502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 300125BN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------