Healthcare Provider Details

I. General information

NPI: 1922777960
Provider Name (Legal Business Name): PRN MEDICAL MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 DONNA DRIVE
WINDSOR CA
95492-9636
US

IV. Provider business mailing address

P.O. BOX 18
FULTON CA
95439-0018
US

V. Phone/Fax

Practice location:
  • Phone: 707-527-7959
  • Fax: 707-527-7959
Mailing address:
  • Phone: 707-527-7959
  • Fax: 707-527-7959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: CHIP DALE SMITH
Title or Position: OWNER
Credential: MMP, HE, ANMT, CMT
Phone: 707-527-7959