Healthcare Provider Details

I. General information

NPI: 1114153012
Provider Name (Legal Business Name): VAN DAVID PORTLOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 EDDY ST ROOM 204
SAN FRANCISCO CA
94109-7846
US

IV. Provider business mailing address

730 EDDY ST ROOM 204
SAN FRANCISCO CA
94109-7846
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-5655
  • Fax: 415-673-1266
Mailing address:
  • Phone: 415-353-5655
  • Fax: 415-673-1266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: