Provider Demographics
NPI:1730301755
Name:IMMUNE ENHANCEMENT PROJECT
Entity Type:Organization
Organization Name:IMMUNE ENHANCEMENT PROJECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NISHANGA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLISS
Authorized Official - Suffix:
Authorized Official - Credentials:LA
Authorized Official - Phone:415-252-8711
Mailing Address - Street 1:3450 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114
Mailing Address - Country:US
Mailing Address - Phone:415-252-8711
Mailing Address - Fax:415-252-8710
Practice Address - Street 1:3450 16TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114
Practice Address - Country:US
Practice Address - Phone:415-252-8711
Practice Address - Fax:415-252-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
CA7355251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health