Provider Demographics
NPI:1477061323
Name:REMEN, JOHN FREDERICK
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FREDERICK
Last Name:REMEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6310
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6310
Mailing Address - Country:US
Mailing Address - Phone:707-443-4237
Mailing Address - Fax:707-442-1191
Practice Address - Street 1:1303 11TH ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-2028
Practice Address - Country:US
Practice Address - Phone:707-443-4237
Practice Address - Fax:707-442-1191
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA015147101YA0400X
CAAII4061214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAII4061214OtherCCAPP