Provider Demographics
NPI:1639602782
Name:VIBRANT NATURAL MEDICINE
Entity Type:Organization
Organization Name:VIBRANT NATURAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:858-361-8158
Mailing Address - Street 1:732 MARLIN AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1895
Mailing Address - Country:US
Mailing Address - Phone:858-361-8158
Mailing Address - Fax:
Practice Address - Street 1:732 MARLIN AVE
Practice Address - Street 2:APT 4
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1895
Practice Address - Country:US
Practice Address - Phone:858-361-8158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17051171100000X
CAND 788175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty