Basic Information
| Provider Information | |||||||||
| NPI: | 1003190299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCAS | ||||||||
| FirstName: | SALVADOR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SUDCC #8399 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 SNEATH LN STE 210 | ||||||||
| Address2: | |||||||||
| City: | SAN BRUNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940662349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502441444 | ||||||||
| FaxNumber: | 6502441447 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BRIARFIELD WAY | ||||||||
| Address2: | |||||||||
| City: | BELMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503694598 | ||||||||
| FaxNumber: | 6502441447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | B1401221633 | 01 | CA | AOD COUNSELOR | OTHER |