Organization
SELF-AWARENESS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEROME MILLER CADC (ECECUTIVE DIRECTOR/COUNSELOR)
(515) 277-0320
Entity
Organization
Contact information
Practice address
2301 FOREST AVE, DES MOINES, IA 50311-3113
(515) 277-0320
(515) 277-0358
Mailing address
2301 FOREST AVE, DES MOINES, IA 50311-3113
(515) 277-0320
(515) 277-0358
Taxonomy
Speciality
Code
Description
License number
State
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
1377
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
601004190
MAGELLAN
IA
Enumeration date
08/26/2015
Last updated
08/26/2015
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