Organization
DUANGTAVAN SOURIVONG
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BOBBY STEARNS MSW (CLINIC DIRECTOR)
(619) 262-8000
Entity
Organization
Contact information
Practice address
3940 HOME AVE, SAN DIEGO, CA 92105-5952
(619) 262-8000
Mailing address
4852 JARRETT CT, SAN DIEGO, CA 92113-3598
Taxonomy
Speciality
Code
Description
License number
State
261QM2800X
Methadone Clinic
Primary
—
CA
Other
Enumeration date
10/02/2007
Last updated
10/02/2007
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