Healthcare Provider Details

I. General information

NPI: 1255257366
Provider Name (Legal Business Name): SUMATINEE BAIBUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 5TH AVE STE B
SAN RAFAEL CA
94901-3269
US

IV. Provider business mailing address

1455 BAY ST APT C
ALAMEDA CA
94501-2351
US

V. Phone/Fax

Practice location:
  • Phone: 415-965-6464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number99171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: