Healthcare Provider Details

I. General information

NPI: 1043670995
Provider Name (Legal Business Name): NATHAN REUBEN BLACKSMITH CADCII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 JULIAN AVE
SAN FRANCISCO CA
94103-3507
US

IV. Provider business mailing address

1702 ARCHER DR
WOODLAND CA
95695-5607
US

V. Phone/Fax

Practice location:
  • Phone: 415-865-0964
  • Fax: 415-865-5428
Mailing address:
  • Phone: 415-865-0964
  • Fax: 415-865-5428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA02670315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: