Healthcare Provider Details

I. General information

NPI: 1366346231
Provider Name (Legal Business Name): ROBERT VIVIAN CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 N PACIFIC COAST HWY STE 150
REDONDO BEACH CA
90277-2107
US

IV. Provider business mailing address

609 N PACIFIC COAST HWY STE 150
REDONDO BEACH CA
90277-2107
US

V. Phone/Fax

Practice location:
  • Phone: 424-257-5648
  • Fax:
Mailing address:
  • Phone: 424-257-5648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: