Provider Demographics
NPI:1508315250
Name:CHANING TIDES TREATMENT
Entity Type:Organization
Organization Name:CHANING TIDES TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:IACULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-415-8781
Mailing Address - Street 1:2021 SPERRY AVE
Mailing Address - Street 2:SUITE 18
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2021 SPERRY AVE
Practice Address - Street 2:SUITE 18
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-7408
Practice Address - Country:US
Practice Address - Phone:844-883-3869
Practice Address - Fax:805-624-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty