Healthcare Provider Details

I. General information

NPI: 1255899134
Provider Name (Legal Business Name): GARY CASIAS CMT #2717
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2019
Last Update Date: 03/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11632 VENTURA BLVD
STUDIO CITY CA
91604-2637
US

IV. Provider business mailing address

11134 MORRISON ST
NORTH HOLLYWOOD CA
91601-4445
US

V. Phone/Fax

Practice location:
  • Phone: 562-652-1412
  • Fax:
Mailing address:
  • Phone: 562-652-1412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: