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General NPI Number Information
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NPI Number | 1811640832
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Entity Type | Individual
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Provider Name | YANDI CAKRASENJAYA LMT, MMP
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Gender | Male
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Dates
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Enumeration Date | 01/31/2022
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Last Update Date | 01/27/2026
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Provider Practice Location Address
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Address Line | 925 W US HIGHWAY 50
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City | PUEBLO
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State | CO
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Zip | 81008-1606
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Country | US
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Telephone | 720-600-9994
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Fax |
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Provider Business Mailing Address
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Address Line | 359 E ENTERPRISE DR STE 7
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City | PUEBLO WEST
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State | CO
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Zip | 81007-1443
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Country | US
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Telephone | 720-600-9994
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | MT.0023692
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License Number State | CO
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