MEDICARE: EVERGREEN ACUPUNCTURE & CHINESE HERBS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC12136	CA

General Provider Information

NPI Number	:	1639306632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN ACUPUNCTURE & CHINESE HERBS, LLC

Provider Business Mailing Address
First Line	:	3375 SCOTT BLVD
Second Line	:	SUITE 332
City	:	SANTA CLARA
State	:	CA
Zip	:	95054-3110
Country	:	US
Telephone Number	:	408-215-1683
Fax Number	:	408-773-6238

Provider Business Practice Location Address
First Line	:	3375 SCOTT BLVD
Second Line	:	SUITE 332
City	:	SANTA CLARA
State	:	CA
Zip	:	95054-3110
Country	:	US
Telephone Number	:	408-215-1683
Fax Number	:	408-773-6238

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. XIN CHANG
Credential	:
Telephone Number	:	408-215-1683

Provider Enumeration Date	:	06/17/2009
Last Update Date	:	06/17/2009

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