Provider Demographics
NPI:1639539661
Name:NIRVANA DRUG AND ALCOHOL TREATMENT INSTITUTE
Entity Type:Organization
Organization Name:NIRVANA DRUG AND ALCOHOL TREATMENT INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II, NADC, SAP
Authorized Official - Phone:209-579-1151
Mailing Address - Street 1:1100 KANSAS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-1596
Mailing Address - Country:US
Mailing Address - Phone:209-579-1151
Mailing Address - Fax:209-579-9605
Practice Address - Street 1:1116 ALICE ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5905
Practice Address - Country:US
Practice Address - Phone:209-578-3132
Practice Address - Fax:209-578-3498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500009GN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA500009GNOtherDEPARTMENT OF HEALTH CARE SERVICES