Healthcare Provider Details

I. General information

NPI: 1497229652
Provider Name (Legal Business Name): TIFFANY BEDOLLA ANMT CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 K ST STE 514
SACRAMENTO CA
95814-3408
US

IV. Provider business mailing address

717 K ST STE 514
SACRAMENTO CA
95814-3408
US

V. Phone/Fax

Practice location:
  • Phone: 630-697-7429
  • Fax:
Mailing address:
  • Phone: 630-697-7429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number69157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: