Healthcare Provider Details

I. General information

NPI: 1316525454
Provider Name (Legal Business Name): IHAB MARDINI MASSAGE THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 NORTHWOOD DR
SAN JOSE CA
95132-1035
US

IV. Provider business mailing address

14665 WASHINGTON AVE APT 12
SAN LEANDRO CA
94578-4229
US

V. Phone/Fax

Practice location:
  • Phone: 801-913-8391
  • Fax:
Mailing address:
  • Phone: 801-913-8391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC37686
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number84443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: