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General NPI Number Information
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NPI Number | 1639539661
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Entity Type | Organization
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Legal Business Name | NIRVANA DRUG AND ALCOHOL TREATMENT INSTITUTE
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Dates
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Enumeration Date | 03/03/2016
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Last Update Date | 03/03/2016
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Provider Practice Location Address
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Address Line | 1116 ALICE ST
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City | MODESTO
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State | CA
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Zip | 95350-5905
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Country | US
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Telephone | 209-578-3132
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Fax | 209-578-3498
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Provider Business Mailing Address
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Address Line | 1100 KANSAS AVE SUITE B
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City | MODESTO
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State | CA
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Zip | 95351-1596
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Country | US
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Telephone | 209-579-1151
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Fax | 209-579-9605
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Authorized Official
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Title or Position | CFO
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Name | MR. MICHAEL EDWARD BAGLEY
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Credential | CADC II, NADC, SAP
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Telephone | 209-579-1151
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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 | 500009GN
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License Number State | CA
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