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General NPI Number Information
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NPI Number | 1780154195
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Entity Type | Organization
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Legal Business Name | KICK THE HABIT ADDICTION MEDICINE, LLC
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Dates
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Enumeration Date | 11/28/2018
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Last Update Date | 03/05/2019
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Provider Practice Location Address
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Address Line | 74 S 360 E
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City | AMERICAN FORK
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State | UT
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Zip | 84003-2590
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Country | US
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Telephone | 949-237-2874
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Fax | 844-240-9439
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Provider Business Mailing Address
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Address Line | 74 S 360 E
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City | AMERICAN FORK
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State | UT
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Zip | 84003-2590
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Country | US
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Telephone | 949-237-2874
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Fax | 844-240-9439
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Authorized Official
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Title or Position | CEO
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Name | ROBERT JOEL BUSH
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Credential | MD
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Telephone | 949-237-2874
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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