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General NPI Number Information
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NPI Number | 1255708855
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Entity Type | Organization
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Legal Business Name | BUPHANT SOCIETY
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Dates
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Enumeration Date | 08/31/2015
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Last Update Date | 08/31/2015
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Provider Practice Location Address
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Address Line | 1045 N. ELDORADO 11
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City | STOCKTON
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State | CA
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Zip | 95202
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Country | US
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Telephone | 209-670-6799
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Fax |
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Provider Business Mailing Address
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Address Line | 1045 N. ELDORADO #11
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City | STOCKTON
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State | CA
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Zip | 95202
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. DAVID GRAYSON
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Credential |
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Telephone | 209-670-6799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | IMF 85548
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License Number State | CA
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