=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992395693
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. KENNETH SCOTT DONAHUE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2021
-----------------------------------------------------
Last Update Date | 01/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2049 SKYLINE DR
-----------------------------------------------------
City | LEMON GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91945-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-465-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1031 LA PRESA AVE
-----------------------------------------------------
City | SPRING VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91977-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-408-0846
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------