Provider Demographics
NPI:1528515061
Name:LLY HEALING CENTER
Entity type:Organization
Organization Name:LLY HEALING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:QI-WEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:408-868-2866
Mailing Address - Street 1:900 S WINCHESTER BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-868-2866
Mailing Address - Fax:
Practice Address - Street 1:900 S WINCHESTER BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2901
Practice Address - Country:US
Practice Address - Phone:408-868-2866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13264171100000X
CAAC10552171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty