=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720921711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTHENTIC HEALING MYOFASCIAL RELEASE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2026
-----------------------------------------------------
Last Update Date | 04/13/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 CHAMPIONSHIP LN
-----------------------------------------------------
City | TEMPLETON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93465-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-391-7701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2464
-----------------------------------------------------
City | PASO ROBLES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93447-2464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-391-7701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MYOFASCIAL RELEASE SPECIALIST
-----------------------------------------------------
Name | LORI A. WHITE
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 805-720-7418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------