Healthcare Provider Details

I. General information

NPI: 1982239331
Provider Name (Legal Business Name): ELENA FIDANOVA CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 06/16/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 ST JOHNS CT
WALNUT CREEK CA
94597-3512
US

IV. Provider business mailing address

33 ST JOHNS CT
WALNUT CREEK CA
94597-3512
US

V. Phone/Fax

Practice location:
  • Phone: 650-255-1155
  • Fax:
Mailing address:
  • Phone: 650-255-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number74934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: