=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992339451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CDT SERVICE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2020
-----------------------------------------------------
Last Update Date | 02/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8078 ORANGE AVE
-----------------------------------------------------
City | FAIR OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95628-5941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-671-3937
-----------------------------------------------------
Fax | 866-336-7276
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11230 GOLD EXPRESS DR # 310-353
-----------------------------------------------------
City | GOLD RIVER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95670-4484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-784-1149
-----------------------------------------------------
Fax | 866-336-7276
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. ROSS STUART MORTON
-----------------------------------------------------
Credential | JD
-----------------------------------------------------
Telephone | 916-784-1149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------