=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225551443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRESSAGE THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2017
-----------------------------------------------------
Last Update Date | 11/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8300 UNIVERSITY AVE
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-9323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-622-1963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8300 UNIVERSITY AVE
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-9323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-622-1963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPORTS REHABILITATION THERAPIST
-----------------------------------------------------
Name | JEREMY ALEXANDER HICKS
-----------------------------------------------------
Credential | CMT
-----------------------------------------------------
Telephone | 619-519-3632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0800X
-----------------------------------------------------
Taxonomy Name | Recovery Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------