Provider Demographics
NPI:1144343138
Name:CAMPOBELLO CHEMICAL DEPENDENCY RECOVERY CENTER
Entity type:Organization
Organization Name:CAMPOBELLO CHEMICAL DEPENDENCY RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:TWITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:707-284-1235
Mailing Address - Street 1:PO BOX 4869
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-4869
Mailing Address - Country:US
Mailing Address - Phone:707-284-1235
Mailing Address - Fax:707-284-1236
Practice Address - Street 1:3250 GUERNEVILLE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4030
Practice Address - Country:US
Practice Address - Phone:707-579-4066
Practice Address - Fax:707-579-1603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490002AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility