Provider Demographics
NPI:1740155712
Name:KELLYS BLOOM LLC
Entity type:Organization
Organization Name:KELLYS BLOOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD
Authorized Official - Prefix:
Authorized Official - First Name:JING
Authorized Official - Middle Name:
Authorized Official - Last Name:KE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:650-383-5041
Mailing Address - Street 1:317 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2816
Mailing Address - Country:US
Mailing Address - Phone:650-383-5041
Mailing Address - Fax:
Practice Address - Street 1:317 STATE ST
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-2816
Practice Address - Country:US
Practice Address - Phone:650-383-5041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KELLYS BLOOM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty