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General NPI Number Information
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NPI Number | 1184435802
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Entity Type | Organization
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Legal Business Name | CUSTOMIZED VETERANS GROUP
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Dates
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Enumeration Date | 01/14/2025
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 578 HARRELL ST
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City | MEMPHIS
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State | TN
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Zip | 38112-2932
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Country | US
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Telephone | 901-907-0640
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Fax | 901-255-0758
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Provider Business Mailing Address
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Address Line | 578 HARRELL ST
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City | MEMPHIS
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State | TN
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Zip | 38112-2932
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Country | US
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Telephone | 901-907-0640
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Fax | 901-255-0758
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | ANTWANE BOHANON
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Credential |
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Telephone | 808-453-0018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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