Healthcare Provider Details

I. General information

NPI: 1104324250
Provider Name (Legal Business Name): SHANNA MARIE BALL C.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIFESTYLE: WELLNESS D/B/A NAME

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 SORRENTO VALLEY BLVD
SAN DIEGO CA
92121-1429
US

IV. Provider business mailing address

12548 OAK KNOLL RD APT C21
POWAY CA
92064-5494
US

V. Phone/Fax

Practice location:
  • Phone: 858-246-9730
  • Fax: 858-246-9710
Mailing address:
  • Phone: 928-216-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number71862
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: