Healthcare Provider Details

I. General information

NPI: 1306180195
Provider Name (Legal Business Name): GENGHONG LIU III ACUPUNCTURIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 ESTUDILLO AVE STE B
SAN LEANDRO CA
94577-4640
US

IV. Provider business mailing address

569 ESTUDILLO AVE APT J
SAN LEANDRO CA
94577-4630
US

V. Phone/Fax

Practice location:
  • Phone: 510-816-1128
  • Fax:
Mailing address:
  • Phone: 510-816-1128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number13797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: