Healthcare Provider Details

I. General information

NPI: 1639602782
Provider Name (Legal Business Name): VIBRANT NATURAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 MARLIN AVE APT 4
FOSTER CITY CA
94404-1895
US

IV. Provider business mailing address

732 MARLIN AVE APT 4
FOSTER CITY CA
94404-1895
US

V. Phone/Fax

Practice location:
  • Phone: 858-361-8158
  • Fax:
Mailing address:
  • Phone: 858-361-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC17051
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND 788
License Number StateCA

VIII. Authorized Official

Name: CHRISTINE K CHANG
Title or Position: OWNER
Credential: ND., LAC
Phone: 858-361-8158