Healthcare Provider Details

I. General information

NPI: 1174010094
Provider Name (Legal Business Name): CUPERTINO HOLISTIC HEALING CLINIC,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20445 PACIFICA DR UNIT 1
CUPERTINO CA
95014-3017
US

IV. Provider business mailing address

20445 PACIFICA DR UNIT 1
CUPERTINO CA
95014-3017
US

V. Phone/Fax

Practice location:
  • Phone: 650-766-8718
  • Fax:
Mailing address:
  • Phone: 650-766-8718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberAC13263
License Number StateCA

VIII. Authorized Official

Name: XIAODAN LI
Title or Position: DOCTOR
Credential: OMD
Phone: 650-766-9718