Provider Demographics
NPI:1548770704
Name:OPIOID & ALCOHOL ADDICTION CLINIC
Entity Type:Organization
Organization Name:OPIOID & ALCOHOL ADDICTION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOPHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KREUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-632-6348
Mailing Address - Street 1:PO BOX 6015
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98063-6015
Mailing Address - Country:US
Mailing Address - Phone:253-332-2958
Mailing Address - Fax:253-838-4145
Practice Address - Street 1:4928 109TH ST SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3731
Practice Address - Country:US
Practice Address - Phone:253-332-2958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health