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General NPI Number Information
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NPI Number | 1558554915
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Entity Type | Organization
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Legal Business Name | PACIFIC VALLEY RECOVERY CENTER INCORPORATED
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Dates
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Enumeration Date | 08/20/2007
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Last Update Date | 08/20/2007
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Provider Practice Location Address
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Address Line | 820 E MAIN ST
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City | STOCKTON
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State | CA
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Zip | 95202-3129
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Country | US
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Telephone | 209-817-5720
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Fax |
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Provider Business Mailing Address
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Address Line | 2491 BURLINGTON PL
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City | STOCKTON
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State | CA
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Zip | 95209-4029
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Country | US
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Telephone | 209-817-5720
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Fax |
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Authorized Official
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Title or Position | CEO/DIRECTOR OF PROGRAMS
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Name | CHARLSIE RUTH HUDSON
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Credential |
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Telephone | 209-817-5720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 390030AN
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License Number State | CA
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