MEDICARE: CRISTA LAKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	9493	CA

General Provider Information

NPI Number	:	1386590594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISTA LAKE

Provider Business Mailing Address
First Line	:	7349 CATALPA AVE
Second Line	:
City	:	CALIFORNIA CITY
State	:	CA
Zip	:	93505-5117
Country	:	US
Telephone Number	:	949-386-4053
Fax Number	:

Provider Business Practice Location Address
First Line	:	7349 CATALPA AVE
Second Line	:
City	:	CALIFORNIA CITY
State	:	CA
Zip	:	93505-5117
Country	:	US
Telephone Number	:	949-386-4053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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Directions to “ CRISTA LAKE ” Practice Location

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