Healthcare Provider Details

I. General information

NPI: 1386065548
Provider Name (Legal Business Name): MAURO HERNANDEZ MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 SIR FRANCIS DRAKE BLVD STE E
SAN ANSELMO CA
94960-2552
US

IV. Provider business mailing address

330 SIR FRANCIS DRAKE BLVD STE E
SAN ANSELMO CA
94960-2552
US

V. Phone/Fax

Practice location:
  • Phone: 917-916-1936
  • Fax: 415-480-1468
Mailing address:
  • Phone: 917-916-1936
  • Fax: 415-480-1468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number94148
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: