Healthcare Provider Details

I. General information

NPI: 1528515061
Provider Name (Legal Business Name): LLY HEALING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S WINCHESTER BLVD SUITE 3
SAN JOSE CA
95128-2901
US

IV. Provider business mailing address

900 S WINCHESTER BLVD SUITE 3
SAN JOSE CA
95128
US

V. Phone/Fax

Practice location:
  • Phone: 408-868-2866
  • Fax:
Mailing address:
  • Phone: 408-868-2866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC13264
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC10552
License Number StateCA

VIII. Authorized Official

Name: MR. QI-WEN SONG
Title or Position: ACUPUNCTURIST
Credential: LAC
Phone: 408-868-2866