Healthcare Provider Details

I. General information

NPI: 1629523543
Provider Name (Legal Business Name): LONGSPRINGHEALTHCENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2016
Last Update Date: 08/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1189 S DE ANZA BLVD STE B
SAN JOSE CA
95129-3662
US

IV. Provider business mailing address

1643 LORIENT TER
SAN JOSE CA
95133-1515
US

V. Phone/Fax

Practice location:
  • Phone: 408-505-9485
  • Fax:
Mailing address:
  • Phone: 408-505-9485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number15474
License Number StateCA

VIII. Authorized Official

Name: SEN WANG
Title or Position: OWNER
Credential: LAC
Phone: 408-505-9485