Provider Demographics
NPI:1245527324
Name:D & A MEN'S DETOX
Entity type:Organization
Organization Name:D & A MEN'S DETOX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZELDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TROUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RAS
Authorized Official - Phone:916-284-1404
Mailing Address - Street 1:9978 FOLSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-1407
Mailing Address - Country:US
Mailing Address - Phone:916-364-3540
Mailing Address - Fax:916-364-3513
Practice Address - Street 1:10590 MALAGA WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-3749
Practice Address - Country:US
Practice Address - Phone:916-361-9867
Practice Address - Fax:916-361-9867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:D & A DETOX CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340035GN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366745622OtherNONE