Healthcare Provider Details

I. General information

NPI: 1730630021
Provider Name (Legal Business Name): MIMI HUANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 BROADWAY
OAKLAND CA
94611-5730
US

IV. Provider business mailing address

785 OAK GROVE RD STE E2 #1180
CONCORD CA
94518-3617
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-1000
  • Fax:
Mailing address:
  • Phone: 925-289-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86077172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: