Provider Demographics
NPI:1275038879
Name:SUN PREVENTION TREATMENT & RECOVERY LLC
Entity Type:Organization
Organization Name:SUN PREVENTION TREATMENT & RECOVERY LLC
Other - Org Name:SUNPTR
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LAADC-CA
Authorized Official - Phone:510-691-0474
Mailing Address - Street 1:4023 W DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4185
Mailing Address - Country:US
Mailing Address - Phone:510-691-0474
Mailing Address - Fax:
Practice Address - Street 1:2017 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-2174
Practice Address - Country:US
Practice Address - Phone:510-691-0474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619306289Medicaid
CALCI10970318OtherLICENSED ADVANCED ALCOHOL AND DRUG COUNSELOR