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General NPI Number Information
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NPI Number | 1992582613
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Entity Type | Organization
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Legal Business Name | PUYALLUP TRIBAL OPIOID CLINIC, INC.
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Dates
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Enumeration Date | 09/14/2023
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Last Update Date | 03/07/2024
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Provider Practice Location Address
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Address Line | 503 EAST 26TH ST
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City | TACOMA
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State | WA
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Zip | 98421
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Country | US
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Telephone | 253-881-7001
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Fax |
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Provider Business Mailing Address
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Address Line | 6650 GUNPARK DR STE 100
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City | BOULDER
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State | CO
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Zip | 80301-7003
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | ROBERT LOUIS KERSHNER
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Credential |
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Telephone | 303-859-2742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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