MEDICARE: CALIFORNIA SPA BOUTIQUE

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	246ZA2600X	Medical Art Specialist/Technologist

General Provider Information

NPI Number	:	1487934360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA SPA BOUTIQUE

Provider Business Mailing Address
First Line	:	413B MONTEREY AVE
Second Line	:
City	:	LOS GATOS
State	:	CA
Zip	:	95030-5302
Country	:	US
Telephone Number	:	408-395-7792
Fax Number	:

Provider Business Practice Location Address
First Line	:	413B MONTEREY AVE
Second Line	:
City	:	LOS GATOS
State	:	CA
Zip	:	95030-5302
Country	:	US
Telephone Number	:	408-395-7792
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JILL HOYER
Credential	:
Telephone Number	:	408-395-7792

Provider Enumeration Date	:	08/23/2011
Last Update Date	:	10/09/2014

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