Healthcare Provider Details

I. General information

NPI: 1134335086
Provider Name (Legal Business Name): MYSTICAL KNOT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 E HILLSDALE BLVD STE 2.6
FOSTER CITY CA
94404-1241
US

IV. Provider business mailing address

5159 BLACKHAWK DR
DANVILLE CA
94506-4572
US

V. Phone/Fax

Practice location:
  • Phone: 925-899-8871
  • Fax:
Mailing address:
  • Phone: 925-899-8871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. AILEEN UY TAN
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 925-899-8871