=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588837033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BULKLEY VENTURES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2008
-----------------------------------------------------
Last Update Date | 04/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 BULKLEY AVE
-----------------------------------------------------
City | SAUSALITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94965-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-332-1350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 BULKLEY AVE
-----------------------------------------------------
City | SAUSALITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94965-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-332-1350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF INTAKE
-----------------------------------------------------
Name | TAMRA ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-332-1350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 210026BP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------