Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003190299 |
---|---|
Provider Name | Mr. Salvador Blancas |
First Address | San Bruno, CA 94066-2349 |
Second Address | Belmont, CA 94002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2011 |
Last Update Date | 27/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B1401221633 | AOD COUNSELOR (01) | CA |