MEDICARE: SLO COUNTY DRUG & ALCOHOL SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency		CA

General Provider Information

NPI Number	:	1316129372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SLO COUNTY DRUG & ALCOHOL SERVICE

Provider Business Mailing Address
First Line	:	1106 E GRAND AVE
Second Line	:	SUITE A
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2516
Country	:	US
Telephone Number	:	805-473-7080
Fax Number	:	805-473-7188

Provider Business Practice Location Address
First Line	:	1106 GRAND AVE
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2516
Country	:	US
Telephone Number	:	805-473-7080
Fax Number	:	805-473-7188

Authorized Official
Title or Position	:	SPECIALIST 1
Name	:	MADALYN BETHANN POWELL
Credential	:	RAS
Telephone Number	:	805-473-7083

Provider Enumeration Date	:	12/03/2007
Last Update Date	:	12/03/2007

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