Healthcare Provider Details

I. General information

NPI: 1316729585
Provider Name (Legal Business Name): MB PHOTOMEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 11/04/2023
Certification Date: 11/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3185 S BASCOM AVE
CAMPBELL CA
95008-6728
US

IV. Provider business mailing address

3185 S BASCOM AVE
CAMPBELL CA
95008-6728
US

V. Phone/Fax

Practice location:
  • Phone: 408-429-8181
  • Fax:
Mailing address:
  • Phone: 408-429-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DUNG LE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 408-429-8181