Healthcare Provider Details

I. General information

NPI: 1285242271
Provider Name (Legal Business Name): SOULSTICE SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2462 W 3RD ST
SANTA ROSA CA
95401-6425
US

IV. Provider business mailing address

512A JOHNSON ST
SAUSALITO CA
94965-2123
US

V. Phone/Fax

Practice location:
  • Phone: 707-843-3539
  • Fax:
Mailing address:
  • Phone: 415-847-1644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: KAYSE GEHRET
Title or Position: FOUNDER
Credential:
Phone: 415-847-1644