Provider Demographics
NPI:1396150074
Name:DIVERSIFIED INTERVENTION GROUP
Entity type:Organization
Organization Name:DIVERSIFIED INTERVENTION GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-602-0681
Mailing Address - Street 1:309 SEQUOIA ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1409
Mailing Address - Country:US
Mailing Address - Phone:805-602-0681
Mailing Address - Fax:
Practice Address - Street 1:309 SEQUOIA ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1409
Practice Address - Country:US
Practice Address - Phone:805-602-0681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-21
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health