Healthcare Provider Details

I. General information

NPI: 1609465392
Provider Name (Legal Business Name): TIDELANDS ACUPUNCTURE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 BROOKGROVE LN
CUPERTINO CA
95014-4667
US

IV. Provider business mailing address

212 S MORRISON AVE
SAN JOSE CA
95126-4826
US

V. Phone/Fax

Practice location:
  • Phone: 408-207-8785
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: HENGJI LI
Title or Position: OWNER
Credential:
Phone: 408-207-8785