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General NPI Number Information
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NPI Number | 1992085674
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Entity Type | Organization
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Legal Business Name | ADDICTIONS & STRESS CLINIC
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Dates
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Enumeration Date | 08/25/2011
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Last Update Date | 08/25/2011
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Provider Practice Location Address
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Address Line | 12 CIVIC CENTER PLZ SUITE 2090
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City | MANKATO
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State | MN
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Zip | 56001-7781
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Country | US
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Telephone | 507-345-4679
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Fax | 507-345-8685
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Provider Business Mailing Address
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Address Line | 12 CIVIC CENTER PLZ SUITE 2090
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City | MANKATO
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State | MN
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Zip | 56001-7781
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Country | US
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Telephone | 507-345-4679
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Fax | 507-345-8685
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. GEORGE V KOMARIDIS
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Credential | PH.D., LP
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Telephone | 507-345-4679
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LP1673
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License Number State | MN
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