Provider Demographics
NPI:1174113963
Name:BODHI ADDICTION TREATMENT AND WELLNESS
Entity type:Organization
Organization Name:BODHI ADDICTION TREATMENT AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAZLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CADC-CAS , RAS II
Authorized Official - Phone:831-600-6021
Mailing Address - Street 1:710 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2780
Mailing Address - Country:US
Mailing Address - Phone:831-600-6021
Mailing Address - Fax:
Practice Address - Street 1:603 CAPITOLA AVE
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2751
Practice Address - Country:US
Practice Address - Phone:831-600-6021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-25
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder