Provider Demographics
NPI:1912738618
Name:ADDICTION CHANGE EXPERTS (ACE) MEDICAL INC
Entity type:Organization
Organization Name:ADDICTION CHANGE EXPERTS (ACE) MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTILLANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-337-6383
Mailing Address - Street 1:595 SAND DOLLAR DR
Mailing Address - Street 2:
Mailing Address - City:LA SELVA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:95076-1815
Mailing Address - Country:US
Mailing Address - Phone:215-356-7136
Mailing Address - Fax:
Practice Address - Street 1:ADDICTION CHANGE EXPERTS (ACE) MEDICAL INC
Practice Address - Street 2:5610 SCOTTS VALLEY DR STE B
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066
Practice Address - Country:US
Practice Address - Phone:408-337-6383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619967007Medicaid