Healthcare Provider Details

I. General information

NPI: 1306412465
Provider Name (Legal Business Name): MICHAEL TEJADA CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2021
Last Update Date: 05/31/2021
Certification Date: 05/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 CHURCH ST STE 109
RANCHO CUCAMONGA CA
91730-6894
US

IV. Provider business mailing address

328 E J ST
ONTARIO CA
91764-2719
US

V. Phone/Fax

Practice location:
  • Phone: 909-285-4561
  • Fax:
Mailing address:
  • Phone: 909-238-5152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number85012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: