Provider Demographics
NPI:1689494262
Name:CONQUER ADDICTION PLLC
Entity type:Organization
Organization Name:CONQUER ADDICTION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:GRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:206-552-0882
Mailing Address - Street 1:809 W MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2172
Mailing Address - Country:US
Mailing Address - Phone:206-552-0882
Mailing Address - Fax:844-440-2147
Practice Address - Street 1:809 W MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2172
Practice Address - Country:US
Practice Address - Phone:206-552-0882
Practice Address - Fax:844-440-2147
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONQUER ADDICTION PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health