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General NPI Number Information
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NPI Number | 1588728679
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Entity Type | Organization
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Legal Business Name | MAYNORD'S CHEMICAL DEPENDENCY RECOVERY CENTERS
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 19325 CHEROKEE RD
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City | TUOLUMNE
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State | CA
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Zip | 95379-9753
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Country | US
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Telephone | 800-228-8208
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Fax | 209-928-1152
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Provider Business Mailing Address
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Address Line | 3717 E THOUSAND OAKS BLVD SUITE 266
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City | WESTLAKE VILLAGE
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State | CA
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Zip | 91362-3607
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Country | US
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Telephone | 805-413-1318
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Fax | 805-413-1304
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Authorized Official
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Title or Position | CREDENTIALING SERVICES MANAGER
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Name | APRIL J ANTONIOU
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Credential |
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Telephone | 805-413-1318
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 550001AP
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License Number State | CA
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