Provider Demographics
NPI:1619275856
Name:1ST CHOICE MEDICAL DETOX
Entity Type:Organization
Organization Name:1ST CHOICE MEDICAL DETOX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:V
Authorized Official - Last Name:KULICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-940-3478
Mailing Address - Street 1:703 S PINELLAS AVE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-3709
Mailing Address - Country:US
Mailing Address - Phone:727-940-3478
Mailing Address - Fax:727-940-3480
Practice Address - Street 1:703 S PINELLAS AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3709
Practice Address - Country:US
Practice Address - Phone:727-940-3478
Practice Address - Fax:727-940-3480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-12
Last Update Date:2011-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 103499207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty