Healthcare Provider Details

I. General information

NPI: 1679069629
Provider Name (Legal Business Name): VINNETTE ANN DETLOFF MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 S GREEN ST
TEHACHAPI CA
93561-1716
US

IV. Provider business mailing address

1105 ALDER AVE
TEHACHAPI CA
93561-2475
US

V. Phone/Fax

Practice location:
  • Phone: 661-527-4146
  • Fax:
Mailing address:
  • Phone: 661-527-4146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number74845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: