Healthcare Provider Details

I. General information

NPI: 1881400117
Provider Name (Legal Business Name): SALAH I QUTOB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 FERNSIDE BLVD
ALAMEDA CA
94501-1760
US

IV. Provider business mailing address

3116 FERNSIDE BLVD
ALAMEDA CA
94501-1760
US

V. Phone/Fax

Practice location:
  • Phone: 510-205-4459
  • Fax:
Mailing address:
  • Phone: 510-205-4459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number97551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: