=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912789777
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS BEAR CMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2023
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 E. DEL MAR BLVD. SUITE 210
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-340-6298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 S. MYRTLE AVE. #507
-----------------------------------------------------
City | MONROVIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-340-6298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 57775
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------