=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972105732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTOR JEROME POITIER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2020
-----------------------------------------------------
Last Update Date | 01/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 856 W 19TH ST
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-5314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-519-8723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2524 W 117TH ST
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-1999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-222-0411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | B001850923
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------