=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538984844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCALISTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2024
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2049 SKYLINE DR
-----------------------------------------------------
City | LEMON GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91945-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-465-7303
-----------------------------------------------------
Fax | 619-337-3610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2049 SKYLINE DR
-----------------------------------------------------
City | LEMON GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91945-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-465-7303
-----------------------------------------------------
Fax | 619-337-3610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OVERNIGHT MONITOR
-----------------------------------------------------
Name | DEVRON YOUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-465-7303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------