1538568845 NPI number — ABUNDANT HEAVEN TRADITIONAL CHINESE MEDICINE

Table of content: (NPI 1538568845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538568845 NPI number — ABUNDANT HEAVEN TRADITIONAL CHINESE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABUNDANT HEAVEN TRADITIONAL CHINESE MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538568845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 E CAMPBELL AVE STE 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMPBELL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95008-2126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-628-1888
Provider Business Mailing Address Fax Number:
408-724-8999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 E CAMPBELL AVE STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMPBELL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95008-2126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-628-1888
Provider Business Practice Location Address Fax Number:
408-724-8999
Provider Enumeration Date:
08/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GIESE-GARDNER
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR & CO-FOUNDER
Authorized Official Telephone Number:
408-628-1888

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC 15236 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ78623Y . This is a "BLUE SHIELD OF CALIFORNIA PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com