Provider Demographics
NPI:1154410652
Name:CALIFORNIA DIVERSION INTERVENTION FOUNDATION
Entity type:Organization
Organization Name:CALIFORNIA DIVERSION INTERVENTION FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MIYAJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-633-0502
Mailing Address - Street 1:1095 N MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5476
Mailing Address - Country:US
Mailing Address - Phone:714-633-0502
Mailing Address - Fax:714-633-9249
Practice Address - Street 1:1095 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5476
Practice Address - Country:US
Practice Address - Phone:714-633-0502
Practice Address - Fax:714-633-9249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300125BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300125BNOtherOUTPATIENT CERTIFICATION