Healthcare Provider Details

I. General information

NPI: 1811193717
Provider Name (Legal Business Name): GUY J VANDENBERG MSW, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 POTRERO AVE BUILDING 80, WARD 86
SAN FRANCISCO CA
94110-2859
US

IV. Provider business mailing address

995 POTRERO AVE BUILDING 80, WARD 86
SAN FRANCISCO CA
94110-2859
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-2482
  • Fax: 415-502-4777
Mailing address:
  • Phone: 415-206-2482
  • Fax: 415-502-4777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number500719
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: