Healthcare Provider Details

I. General information

NPI: 1093709206
Provider Name (Legal Business Name): TIDES CENTERINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 FILLIMORE ST
SAN FRANCISCO CA
94115
US

IV. Provider business mailing address

1833 FILLIMORE ST
SAN FRANCISCO CA
94115
US

V. Phone/Fax

Practice location:
  • Phone: 415-379-7800
  • Fax: 415-379-7804
Mailing address:
  • Phone: 415-379-7800
  • Fax: 415-379-7804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number220000401
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARLINA F. HANSEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 415-379-7800