Provider Demographics
NPI:1205529252
Name:ROOTS ADDICTION AND PSYCHIATRY MEDICAL GROUP, PC
Entity type:Organization
Organization Name:ROOTS ADDICTION AND PSYCHIATRY MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREI
Authorized Official - Middle Name:
Authorized Official - Last Name:DOKUKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-304-9592
Mailing Address - Street 1:3939 ATLANTIC AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3529
Mailing Address - Country:US
Mailing Address - Phone:562-473-0825
Mailing Address - Fax:562-473-0825
Practice Address - Street 1:3939 ATLANTIC AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3529
Practice Address - Country:US
Practice Address - Phone:562-473-0825
Practice Address - Fax:562-473-0825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-26
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty