MEDICARE: MRS. LIUDMYLA VERETILNYK CMT

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	56549	CA

General Provider Information

NPI Number	:	1710592456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LIUDMYLA VERETILNYK CMT

Provider Business Mailing Address
First Line	:	5248 LOCKWOOD CIR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-2750
Country	:	US
Telephone Number	:	707-508-7988
Fax Number	:

Provider Business Practice Location Address
First Line	:	838 4TH ST STE A
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-4538
Country	:	US
Telephone Number	:	707-508-7988
Fax Number	:

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

Provider Enumeration Date	:	09/10/2020
Last Update Date	:	09/10/2020

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