=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982000691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC SAMUEL HAYNES PHD, MATCM, LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2014
-----------------------------------------------------
Last Update Date | 03/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10580 S DE ANZA BLVD
-----------------------------------------------------
City | CUPERTINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95014-4450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-785-6888
-----------------------------------------------------
Fax | 888-391-8562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 695 TASMAN DR APT. 3213
-----------------------------------------------------
City | SUNNYVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94089-4746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-785-6888
-----------------------------------------------------
Fax | 888-391-8562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 16760
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------