Healthcare Provider Details

I. General information

NPI: 1790501823
Provider Name (Legal Business Name): PHOENIX EMOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 SUNNE LN STE 112
WALNUT CREEK CA
94597-3634
US

IV. Provider business mailing address

7000 SUNNE LN STE 112
WALNUT CREEK CA
94597-3634
US

V. Phone/Fax

Practice location:
  • Phone: 925-378-5453
  • Fax:
Mailing address:
  • Phone: 925-378-5453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9878
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: