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General NPI Number Information
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NPI Number | 1336958966
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Entity Type | Individual
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Provider Name | GREG MACK TRIKALA
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Gender | Male
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Dates
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Enumeration Date | 01/07/2025
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 3707 SUNSET LN
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City | ANTIOCH
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State | CA
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Zip | 94509-6101
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Country | US
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Telephone | 925-281-3500
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Fax |
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Provider Business Mailing Address
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Address Line | 4548 SWEET WATER ST
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City | ANTIOCH
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State | CA
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Zip | 94531-7183
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Country | US
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Telephone | 415-286-0434
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | R1593261224
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License Number State | CA
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