Provider Demographics
NPI:1255624821
Name:SOUTHBAY PAIN & SPORTS MEDICINE ACUPUNCTURE
Entity type:Organization
Organization Name:SOUTHBAY PAIN & SPORTS MEDICINE ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKI
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:408-605-1471
Mailing Address - Street 1:PO BOX 610110
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-0110
Mailing Address - Country:US
Mailing Address - Phone:408-605-1471
Mailing Address - Fax:
Practice Address - Street 1:2920 BROADWAY
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-1578
Practice Address - Country:US
Practice Address - Phone:408-600-1513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14131171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty