Healthcare Provider Details

I. General information

NPI: 1407039118
Provider Name (Legal Business Name): EVERBLOSSOM HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 S DE ANZA BLVD. SUITE A
SAN JOSE CA
95129
US

IV. Provider business mailing address

12111 KIRKBROOK DR
SARATOGA CA
95070
US

V. Phone/Fax

Practice location:
  • Phone: 408-410-7821
  • Fax: 408-253-2842
Mailing address:
  • Phone: 408-410-7821
  • Fax: 408-253-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC11253
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberAC11253
License Number StateCA

VIII. Authorized Official

Name: MS. ANN TUNG
Title or Position: OWNER
Credential:
Phone: 408-410-7821