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General NPI Number Information
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NPI Number | 1902376304
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Entity Type | Individual
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Provider Name | ILANA CELESTE RYAVEC-GORANSON RD
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Gender | Female
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Dates
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Enumeration Date | 11/28/2018
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Last Update Date | 11/28/2018
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Provider Practice Location Address
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Address Line | 488 MAIN ST STE 200B
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City | MURPHYS
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State | CA
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Zip | 95247-9384
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Country | US
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Telephone | 209-559-2228
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Fax |
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Provider Business Mailing Address
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Address Line | 270 WYLDEWOOD DR
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City | MURPHYS
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State | CA
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Zip | 95247-9502
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Country | US
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Telephone | 209-559-2228
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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 | 19258
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 86112557
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License Number State | CA
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