Provider Demographics
NPI:1255001624
Name:CONQUER ADDICTION PLLC
Entity Type:Organization
Organization Name:CONQUER ADDICTION PLLC
Other - Org Name:CONQUER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, PA-C
Authorized Official - Phone:425-387-1863
Mailing Address - Street 1:19916 OLD OWEN RD # 510
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9778
Mailing Address - Country:US
Mailing Address - Phone:360-453-7715
Mailing Address - Fax:
Practice Address - Street 1:809 W MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2172
Practice Address - Country:US
Practice Address - Phone:206-552-0882
Practice Address - Fax:844-440-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health