Basic Information
| Provider Information | |||||||||
| NPI: | 1396231635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAL | ||||||||
| FirstName: | GENEVIEVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1920 FRANCISCO ST APT 208 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947092103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412212357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2712 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154012700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2018 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.