Healthcare Provider Details

I. General information

NPI: 1376001347
Provider Name (Legal Business Name): DIANA LUGO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 HUTCHINS ST
SANTA RITA GU
96915-1163
US

IV. Provider business mailing address

7 HUTCHINS ST
SANTA RITA GU
96915-1163
US

V. Phone/Fax

Practice location:
  • Phone: 671-480-7208
  • Fax:
Mailing address:
  • Phone: 671-480-7208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number72958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: