Healthcare Provider Details

I. General information

NPI: 1609351212
Provider Name (Legal Business Name): SALUSTIANO RIBEIRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 JERROLD AVE APT 311
SAN FRANCISCO CA
94124-3045
US

IV. Provider business mailing address

50 JERROLD AVE APT 311
SAN FRANCISCO CA
94124-3045
US

V. Phone/Fax

Practice location:
  • Phone: 510-910-2296
  • Fax:
Mailing address:
  • Phone: 510-910-2296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number16176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: