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General NPI Number Information
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NPI Number | 1649663527
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Entity Type | Organization
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Legal Business Name | LISA GONZALEZ
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Dates
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Enumeration Date | 03/16/2015
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Last Update Date | 03/16/2015
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Provider Practice Location Address
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Address Line | 3446 PARK BLVD
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City | SAN DIEGO
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State | CA
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Zip | 92103-5209
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Country | US
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Telephone | 619-807-2130
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Fax |
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Provider Business Mailing Address
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Address Line | 3446 PARK BLVD
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City | SAN DIEGO
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State | CA
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Zip | 92103-5209
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Country | US
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Telephone | 619-807-2130
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Fax |
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST
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Name | LISA GONZALEZ
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Credential | L.M.T.
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Telephone | 619-807-2130
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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 | 19498
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License Number State | CA
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