Healthcare Provider Details

I. General information

NPI: 1912372541
Provider Name (Legal Business Name): OLEG BOUIMER CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23440 CIVIC CENTER WAY SUITE 202
MALIBU CA
90265-4854
US

IV. Provider business mailing address

23440 CIVIC CENTER WAY SUITE 202
MALIBU CA
90265-4854
US

V. Phone/Fax

Practice location:
  • Phone: 310-317-9500
  • Fax: 310-317-9502
Mailing address:
  • Phone: 310-317-9500
  • Fax: 310-317-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number24838
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: