=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487358230
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SITHY BIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2023
-----------------------------------------------------
Last Update Date | 03/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8145 CANBY AVE UNIT 3
-----------------------------------------------------
City | RESEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91335-3143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-239-9266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8145 CANBY AVE UNIT 3
-----------------------------------------------------
City | RESEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91335-3143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-239-9266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | MPSS-DJKRWT
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------