Healthcare Provider Details

I. General information

NPI: 1154183663
Provider Name (Legal Business Name): LEA MARISA GAMILLO MT, HHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 ADOBE NORTE AVE
FALLBROOK CA
92028-4201
US

IV. Provider business mailing address

1130 ADOBE NORTE AVE
FALLBROOK CA
92028-4201
US

V. Phone/Fax

Practice location:
  • Phone: 760-685-5258
  • Fax:
Mailing address:
  • Phone: 760-685-5258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number94422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: