Provider Demographics
NPI:1992085674
Name:ADDICTIONS & STRESS CLINIC
Entity type:Organization
Organization Name:ADDICTIONS & STRESS CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:V
Authorized Official - Last Name:KOMARIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:507-345-4679
Mailing Address - Street 1:12 CIVIC CENTER PLZ
Mailing Address - Street 2:SUITE 2090
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7781
Mailing Address - Country:US
Mailing Address - Phone:507-345-4679
Mailing Address - Fax:507-345-8685
Practice Address - Street 1:12 CIVIC CENTER PLZ
Practice Address - Street 2:SUITE 2090
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7781
Practice Address - Country:US
Practice Address - Phone:507-345-4679
Practice Address - Fax:507-345-8685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1673251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health