=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861968323
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKEN HAROUT BALIAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2018
-----------------------------------------------------
Last Update Date | 10/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 SPRUCE AVE
-----------------------------------------------------
City | SOUTH SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94080-2741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-589-9305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 SLOAT BLVD
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94116-2824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-690-4449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------