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General NPI Number Information
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NPI Number | 1447361597
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Entity Type | Organization
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Legal Business Name | EVERGREEN ACUPUNTURE CLINIC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2040 FOREST AVE SUITE 8
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City | SAN JOSE
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State | CA
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Zip | 95128-4816
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Country | US
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Telephone | 408-288-8238
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Fax | 408-369-8866
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Provider Business Mailing Address
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Address Line | 2040 FOREST AVE SUITE 8
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City | SAN JOSE
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State | CA
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Zip | 95128-4816
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Country | US
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Telephone | 408-288-8238
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Fax | 408-369-8866
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Authorized Official
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Title or Position | PRESIDENT/ACUPUNTURIST
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Name | SANDY HONG WONG
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Credential | LAC
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Telephone | 408-288-8238
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC7393
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License Number State | CA
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