Healthcare Provider Details

I. General information

NPI: 1457047847
Provider Name (Legal Business Name): JOSHUA SAMUEL CEBALLOS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 DOVER DR STE 234
NEWPORT BEACH CA
92660-5515
US

IV. Provider business mailing address

901 DOVER DR STE 234
NEWPORT BEACH CA
92660-5515
US

V. Phone/Fax

Practice location:
  • Phone: 949-642-8193
  • Fax: 949-325-0817
Mailing address:
  • Phone: 949-642-8193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number87240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: