Healthcare Provider Details

I. General information

NPI: 1275289159
Provider Name (Legal Business Name): SOUTH BAY SERENITY AND GUIDANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 LIQUID LN
CHULA VISTA CA
91915-3300
US

IV. Provider business mailing address

1830 LIQUID LN
CHULA VISTA CA
91915-3300
US

V. Phone/Fax

Practice location:
  • Phone: 714-809-7450
  • Fax:
Mailing address:
  • Phone: 714-809-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KIRAN VIRANI
Title or Position: CEO
Credential:
Phone: 714-809-7450