Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 18679 | CA |
NPI | 1013004571 |
---|---|
Provider Name | Ishan Balthazar Vest |
First Address | Daly City, CA 94015-1908 |
Second Address | Daly City, CA 94015-1908 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC0186790 | (02) | CA |
DC0186790 | BLUE SHIELD (01) | CA |