Provider Demographics
NPI:1134335086
Name:MYSTICAL KNOT, LLC
Entity type:Organization
Organization Name:MYSTICAL KNOT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AILEEN
Authorized Official - Middle Name:UY
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-899-8871
Mailing Address - Street 1:5159 BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4572
Mailing Address - Country:US
Mailing Address - Phone:925-899-8871
Mailing Address - Fax:
Practice Address - Street 1:1241 E HILLSDALE BLVD
Practice Address - Street 2:STE 2.6
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1241
Practice Address - Country:US
Practice Address - Phone:925-899-8871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty