MEDICARE: SOUTHBAY PAIN & SPORTS MEDICINE ACUPUNCTURE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	14131	CA

General Provider Information

NPI Number	:	1255624821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHBAY PAIN & SPORTS MEDICINE ACUPUNCTURE

Provider Business Mailing Address
First Line	:	PO BOX 610110
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94061-0110
Country	:	US
Telephone Number	:	408-605-1471
Fax Number	:

Provider Business Practice Location Address
First Line	:	2920 BROADWAY
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94062-1578
Country	:	US
Telephone Number	:	408-600-1513
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MIKI HIGUCHI
Credential	:	L.AC.
Telephone Number	:	408-605-1471

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	07/27/2016

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