Healthcare Provider Details

I. General information

NPI: 1902727167
Provider Name (Legal Business Name): ISRAEL SAGRERO-SALAZAR SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 SOUTHGATE AVE
DALY CITY CA
94015-3937
US

IV. Provider business mailing address

39 BRUTON ST APT 1703
SAN FRANCISCO CA
94130-1675
US

V. Phone/Fax

Practice location:
  • Phone: 650-244-1444
  • Fax:
Mailing address:
  • Phone: 503-932-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: