Healthcare Provider Details

I. General information

NPI: 1053241539
Provider Name (Legal Business Name): TAYNA LEE HODGE MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 RESERVATION RD APT 115
MARINA CA
93933-3190
US

IV. Provider business mailing address

269 RESERVATION RD APT 115
MARINA CA
93933-3190
US

V. Phone/Fax

Practice location:
  • Phone: 831-917-7008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number36725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: