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General NPI Number Information
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NPI Number | 1619275856
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Entity Type | Organization
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Legal Business Name | 1ST CHOICE MEDICAL DETOX
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Dates
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Enumeration Date | 03/12/2011
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Last Update Date | 03/12/2011
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Provider Practice Location Address
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Address Line | 703 S PINELLAS AVE
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City | TARPON SPRINGS
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State | FL
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Zip | 34689-3709
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Country | US
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Telephone | 727-940-3478
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Fax | 727-940-3480
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Provider Business Mailing Address
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Address Line | 703 S PINELLAS AVE
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City | TARPON SPRINGS
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State | FL
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Zip | 34689-3709
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Country | US
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Telephone | 727-940-3478
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Fax | 727-940-3480
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARINA V KULICK
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Credential | MD
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Telephone | 727-940-3478
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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 | ME 103499
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License Number State | FL
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