Healthcare Provider Details

I. General information

NPI: 1750693123
Provider Name (Legal Business Name): KIMBERLY LAIN URETA CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17685 1/2 VERDE ST
HESPERIA CA
92345-5442
US

IV. Provider business mailing address

9179 G AVE
HESPERIA CA
92345-6121
US

V. Phone/Fax

Practice location:
  • Phone: 760-646-3140
  • Fax:
Mailing address:
  • Phone: 760-646-3140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: