=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891496881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D&T WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2023
-----------------------------------------------------
Last Update Date | 03/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17633 NORDHOFF ST
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-800-1645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 COTTAGE WAY STE G2
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-1474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-800-1645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANTHONY RAFAEL MORENO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-420-8025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------