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General NPI Number Information
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NPI Number | 1326337684
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Entity Type | Organization
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Legal Business Name | BLANACED BODY THERAPEUTIC MASSAGE
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Dates
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Enumeration Date | 04/07/2011
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Last Update Date | 04/07/2011
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Provider Practice Location Address
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Address Line | 1991 VILLAGE PARK WAY SUITE 206-A
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City | ENCINITAS
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State | CA
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Zip | 92024-1994
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Country | US
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Telephone | 760-216-4270
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Fax |
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Provider Business Mailing Address
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Address Line | 1820 MELROSE DR #331
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City | SAN MARCOS
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State | CA
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Zip | 92078-2116
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Country | US
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Telephone | 760-216-4270
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/MASSAGE THERAPIST
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Name | MR. PHILIPPE COUDOUX
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Credential | HHP, CMT
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Telephone | 760-216-4270
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 10215
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License Number State | CA
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