Healthcare Provider Details

I. General information

NPI: 1548179724
Provider Name (Legal Business Name): TANESHA NA QUA WILCOTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 W RIALTO AVE APT C
SAN BERNARDINO CA
92408-1159
US

IV. Provider business mailing address

146 W RIALTO AVE APT C
SAN BERNARDINO CA
92408-1159
US

V. Phone/Fax

Practice location:
  • Phone: 909-277-5843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number92688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: