Healthcare Provider Details

I. General information

NPI: 1679804850
Provider Name (Legal Business Name): GONG WEN SHI MASSAGE THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7151 AMADOR PLAZA RD
DUBLIN CA
94568-2317
US

IV. Provider business mailing address

2892 23RD ST
SAN FRANCISCO CA
94110-3444
US

V. Phone/Fax

Practice location:
  • Phone: 925-833-9555
  • Fax: 415-762-1960
Mailing address:
  • Phone: 415-867-7775
  • Fax: 415-762-1960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberSC 21939867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: