Healthcare Provider Details

I. General information

NPI: 1710749494
Provider Name (Legal Business Name): LGTC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 W SAN CARLOS ST
SAN JOSE CA
95110-2627
US

IV. Provider business mailing address

4850 UNION AVE
SAN JOSE CA
95124-5156
US

V. Phone/Fax

Practice location:
  • Phone: 408-559-3403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: EUGENE TILMAN
Title or Position: DIRECTOR
Credential:
Phone: 408-559-3403