Provider Demographics
NPI:1447361597
Name:EVERGREEN ACUPUNTURE CLINIC
Entity type:Organization
Organization Name:EVERGREEN ACUPUNTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ACUPUNTURIST
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:HONG
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:408-288-8238
Mailing Address - Street 1:2040 FOREST AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4816
Mailing Address - Country:US
Mailing Address - Phone:408-288-8238
Mailing Address - Fax:408-369-8866
Practice Address - Street 1:2040 FOREST AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4816
Practice Address - Country:US
Practice Address - Phone:408-288-8238
Practice Address - Fax:408-369-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7393171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty