1639356710 NPI number — LIVE WELL CHINESE MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639356710 NPI number — LIVE WELL CHINESE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVE WELL 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:
1639356710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1932 PARKWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94403-3961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-235-2710
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2041 PIONEER CT
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94403-1786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-525-9355
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KAN
Authorized Official First Name:
EUNICE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
LICENSED ACUPUNCTURIST & HERBALIST
Authorized Official Telephone Number:
415-235-2710

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  11878 , 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: ZZZ50676Y . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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