Healthcare Provider Details

I. General information

NPI: 1740123082
Provider Name (Legal Business Name): NELSON EDILIO PLAZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 CORNELL DR
BURBANK CA
91504-4032
US

IV. Provider business mailing address

523 CORNELL DR
BURBANK CA
91504-4032
US

V. Phone/Fax

Practice location:
  • Phone: 747-474-8541
  • Fax:
Mailing address:
  • Phone: 747-474-8541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number92500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: