Healthcare Provider Details

I. General information

NPI: 1417756636
Provider Name (Legal Business Name): SOPHIA JUAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 FANUEL ST
SAN DIEGO CA
92109-2904
US

IV. Provider business mailing address

5150 GALT WAY
SAN DIEGO CA
92117-1128
US

V. Phone/Fax

Practice location:
  • Phone: 858-200-6462
  • Fax:
Mailing address:
  • Phone: 858-200-6462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number78792
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: