Healthcare Provider Details

I. General information

NPI: 1255003729
Provider Name (Legal Business Name): GENESIS ESPITIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21051 LASSEN ST APT 29
CHATSWORTH CA
91311-4248
US

IV. Provider business mailing address

21051 LASSEN ST APT 29
CHATSWORTH CA
91311-4248
US

V. Phone/Fax

Practice location:
  • Phone: 818-966-5870
  • Fax:
Mailing address:
  • Phone: 818-966-5870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number84217
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: