=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932839750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EPHRAIM ALEJANDRO DELGADILLO JR. CADC-I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2022
-----------------------------------------------------
Last Update Date | 06/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18670 CARTER ST.
-----------------------------------------------------
City | TUOLUMNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95379-9537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-352-6632
-----------------------------------------------------
Fax | 209-206-4163
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18880 CHERRY VALLEY BLVD
-----------------------------------------------------
City | TUOLUMNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95379-9506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-352-6632
-----------------------------------------------------
Fax | 209-206-4163
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CI32200321
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------