Healthcare Provider Details

I. General information

NPI: 1205740198
Provider Name (Legal Business Name): AMBER C DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 SYCAMORE CT APT A
UPLAND CA
91786-8600
US

IV. Provider business mailing address

905 SYCAMORE CT APT A
UPLAND CA
91786-8600
US

V. Phone/Fax

Practice location:
  • Phone: 951-466-9388
  • Fax:
Mailing address:
  • Phone: 951-466-9388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number62841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: