Provider Demographics
NPI:1780154195
Name:KICK THE HABIT ADDICTION MEDICINE, LLC
Entity type:Organization
Organization Name:KICK THE HABIT ADDICTION MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-237-2874
Mailing Address - Street 1:74 S 360 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2590
Mailing Address - Country:US
Mailing Address - Phone:949-237-2874
Mailing Address - Fax:844-240-9439
Practice Address - Street 1:74 S 360 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2590
Practice Address - Country:US
Practice Address - Phone:949-237-2874
Practice Address - Fax:844-240-9439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty