Healthcare Provider Details

I. General information

NPI: 1174223580
Provider Name (Legal Business Name): TINA TJAHJADI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LELAND AVE APT A
SAN FRANCISCO CA
94134-2806
US

IV. Provider business mailing address

120 LELAND AVE APT A
SAN FRANCISCO CA
94134-2806
US

V. Phone/Fax

Practice location:
  • Phone: 415-975-1263
  • Fax:
Mailing address:
  • Phone: 415-975-1263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19015
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: