=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811273865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHRIGHT 360
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2011
-----------------------------------------------------
Last Update Date | 05/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 W 22ND ST FL 1
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90007-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-741-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1735 MISSION ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94103-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-762-3700
-----------------------------------------------------
Fax | 415-865-0119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. VITKA EISEN
-----------------------------------------------------
Credential | MSW, ED
-----------------------------------------------------
Telephone | 415-762-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 190728CN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------