Provider Demographics
NPI:1467908855
Name:THE JUANITA CENTER LLC
Entity Type:Organization
Organization Name:THE JUANITA CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:CDP, SAP, NCAC
Authorized Official - Phone:425-328-9528
Mailing Address - Street 1:627 5TH ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-1580
Mailing Address - Country:US
Mailing Address - Phone:425-328-9528
Mailing Address - Fax:425-786-9276
Practice Address - Street 1:627 5TH ST
Practice Address - Street 2:SUITE 100A
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-1580
Practice Address - Country:US
Practice Address - Phone:425-328-9528
Practice Address - Fax:425-786-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA31-1480-00261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder