Provider Demographics
NPI:1265819288
Name:ADDICTION THERAPY PC
Entity type:Organization
Organization Name:ADDICTION THERAPY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DATSON
Authorized Official - Last Name:HERNDON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:206-852-8815
Mailing Address - Street 1:559 S PALM CANYON DR STE 207
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-7468
Mailing Address - Country:US
Mailing Address - Phone:951-852-6284
Mailing Address - Fax:
Practice Address - Street 1:559 S PALM CANYON DR STE 207
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-7468
Practice Address - Country:US
Practice Address - Phone:951-852-6284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16694261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care