Healthcare Provider Details

I. General information

NPI: 1548854201
Provider Name (Legal Business Name): NYANISO RAHOTEP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 W 54TH ST
LOS ANGELES CA
90043-2306
US

IV. Provider business mailing address

3466 S CLOVERDALE AVE
LOS ANGELES CA
90016-5214
US

V. Phone/Fax

Practice location:
  • Phone: 323-639-3191
  • Fax:
Mailing address:
  • Phone: 323-793-1159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number121647
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: