Healthcare Provider Details

I. General information

NPI: 1184213050
Provider Name (Legal Business Name): MS. MYRIAM LIBERTY KOPPELMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4337 MARINA CITY DR # 947ETN
MARINA DEL REY CA
90292-5813
US

IV. Provider business mailing address

4337 MARINA CITY DR # 947ETN
MARINA DEL REY CA
90292-5813
US

V. Phone/Fax

Practice location:
  • Phone: 310-435-5003
  • Fax:
Mailing address:
  • Phone: 310-435-5003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number73597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: