Healthcare Provider Details

I. General information

NPI: 1366982316
Provider Name (Legal Business Name): DAVINA GELARDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 E HIGHWAY 54
ATHOL ID
83801-6085
US

IV. Provider business mailing address

PO BOX 872
ATHOL ID
83801-0872
US

V. Phone/Fax

Practice location:
  • Phone: 208-920-0825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-2103
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: