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General NPI Number Information
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NPI Number | 1174113963
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Entity Type | Organization
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Legal Business Name | BODHI ADDICTION TREATMENT AND WELLNESS
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Dates
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Enumeration Date | 01/25/2021
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Last Update Date | 01/26/2021
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Provider Practice Location Address
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Address Line | 603 CAPITOLA AVE
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City | CAPITOLA
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State | CA
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Zip | 95010-2751
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Country | US
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Telephone | 831-600-6021
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Fax |
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Provider Business Mailing Address
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Address Line | 710 BEVERLY AVE
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City | CAPITOLA
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State | CA
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Zip | 95010-2780
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Country | US
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Telephone | 831-600-6021
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JONATHAN BEAZLEY
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Credential | CADC-CAS , RAS II
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Telephone | 831-600-6021
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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