=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326611682
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDELARIO TABLASON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2021
-----------------------------------------------------
Last Update Date | 07/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16025 GALE AVE STE B7
-----------------------------------------------------
City | CITY OF INDUSTRY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91745-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-333-3172
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15135 EUCALYPTUS AVE
-----------------------------------------------------
City | BELLFLOWER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90706-3701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-301-5182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 40319
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------