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General NPI Number Information
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NPI Number | 1508315250
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Entity Type | Organization
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Legal Business Name | CHANING TIDES TREATMENT
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Dates
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Enumeration Date | 09/22/2016
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Last Update Date | 09/22/2016
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Provider Practice Location Address
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Address Line | 2021 SPERRY AVE SUITE 18
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City | VENTURA
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State | CA
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Zip | 93003-7408
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Country | US
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Telephone | 844-883-3869
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Fax | 805-624-5311
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Provider Business Mailing Address
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Address Line | 2021 SPERRY AVE SUITE 18
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City | VENTURA
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State | CA
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Zip | 93003-7408
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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 | BILLING
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Name | ANGELA IACULLO
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Credential |
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Telephone | 954-415-8781
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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