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General NPI Number Information
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NPI Number | 1588106942
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Entity Type | Organization
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Legal Business Name | SPORTS MASSAGE MARIN
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Dates
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Enumeration Date | 11/15/2016
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Last Update Date | 11/15/2016
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Provider Practice Location Address
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Address Line | 645 TAMALPAIS DR
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City | CORTE MADERA
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State | CA
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Zip | 94925-1613
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Country | US
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Telephone | 415-310-0878
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Fax |
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Provider Business Mailing Address
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Address Line | 645 TAMALPAIS DR
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City | CORTE MADERA
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State | CA
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Zip | 94925-1613
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Country | US
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Telephone | 415-310-0878
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Fax |
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Authorized Official
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Title or Position | GENERAL PARTNER
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Name | STEFAN SMITH
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Credential |
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Telephone | 415-310-0878
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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