Healthcare Provider Details

I. General information

NPI: 1750955381
Provider Name (Legal Business Name): MASSAGE FOR ATHLETES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 AVIATION BLVD STE D
SANTA ROSA CA
95403-1074
US

IV. Provider business mailing address

418 AVIATION BLVD STE D
SANTA ROSA CA
95403-1074
US

V. Phone/Fax

Practice location:
  • Phone: 707-541-6258
  • Fax: 707-284-0122
Mailing address:
  • Phone: 707-541-6258
  • Fax: 707-284-0122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name: CORALIE JENNER
Title or Position: OWNER/CEO
Credential:
Phone: 707-541-6258