Provider Demographics
NPI:1932391638
Name:MB LASER REHAB CENTER
Entity Type:Organization
Organization Name:MB LASER REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-406-8889
Mailing Address - Street 1:3395 HERITAGE ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3804
Mailing Address - Country:US
Mailing Address - Phone:408-406-8889
Mailing Address - Fax:408-283-9318
Practice Address - Street 1:519 PARROTT ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4121
Practice Address - Country:US
Practice Address - Phone:408-406-8889
Practice Address - Fax:408-283-9318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30915111NR0400X
CADC29924111NR0400X
CADC27342111NR0400X
CADC30725111NR0400X
CAAC11053171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty