Healthcare Provider Details

I. General information

NPI: 1497691653
Provider Name (Legal Business Name): MR. GARY LYN ROSENTHAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CALLE AMANECER STE 320
SAN CLEMENTE CA
92673-4222
US

IV. Provider business mailing address

221 CAMINO SAN CLEMENTE
SAN CLEMENTE CA
92672-3703
US

V. Phone/Fax

Practice location:
  • Phone: 949-366-6785
  • Fax:
Mailing address:
  • Phone: 714-600-5897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number43137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: