MEDICARE: ADI-OP, INC.

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	430068AP	CA

General Provider Information

NPI Number	:	1861939365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADI-OP, INC.

Provider Business Mailing Address
First Line	:	1900 CAMDEN AVE
Second Line	:	STE 205
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2942
Country	:	US
Telephone Number	:	408-879-7581
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 CAMDEN AVE
Second Line	:	STE 205
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2942
Country	:	US
Telephone Number	:	408-879-7581
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MISS MELISSA BLAIRE SHAWHAN
Credential	:
Telephone Number	:	408-879-7581

Provider Enumeration Date	:	01/23/2017
Last Update Date	:	01/23/2017

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