Healthcare Provider Details

I. General information

NPI: 1366054215
Provider Name (Legal Business Name): WILLIAM JOSEPH THERIAULT MASSAGE PRACTITIONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 WARNER AVE SUITE 100
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

2601 HUNTINGTON ST. #7
HUNTINGTON BEACH CA
92648
US

V. Phone/Fax

Practice location:
  • Phone: 714-898-0515
  • Fax:
Mailing address:
  • Phone: 714-260-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: