Healthcare Provider Details

I. General information

NPI: 1578486718
Provider Name (Legal Business Name): KEDDRYONA WARREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20140 ROSCOE BLVD APT 103
WINNETKA CA
91306-1651
US

IV. Provider business mailing address

20140 ROSCOE BLVD APT 103
WINNETKA CA
91306-1651
US

V. Phone/Fax

Practice location:
  • Phone: 803-878-9652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number102029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: