Healthcare Provider Details

I. General information

NPI: 1043655202
Provider Name (Legal Business Name): GREEN JADE ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 ALTON PKWY SUITE 158
IRVINE CA
92618-1617
US

IV. Provider business mailing address

13700 ALTON PKWY SUITE 158
IRVINE CA
92618-1617
US

V. Phone/Fax

Practice location:
  • Phone: 949-278-3642
  • Fax:
Mailing address:
  • Phone: 949-278-3642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15129
License Number StateCA

VIII. Authorized Official

Name: MR. CHRIS CHARLES BRUCKNER
Title or Position: PRESIDENT
Credential: L.AC.
Phone: 949-278-3642