MEDICARE: YOUR SPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302R00000X	Health Maintenance Organization	32539	CA

General Provider Information

NPI Number	:	1134668452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR SPA

Provider Business Mailing Address
First Line	:	3609 4TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4105
Country	:	US
Telephone Number	:	619-255-0789
Fax Number	:

Provider Business Practice Location Address
First Line	:	3609 4TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4105
Country	:	US
Telephone Number	:	619-255-0789
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MASSAGE THERAPIST
Name	:	MRS. ANTOINETT M CASTRO
Credential	:	32539
Telephone Number	:	619-255-0789

Provider Enumeration Date	:	02/20/2017
Last Update Date	:	02/20/2017

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Directions to “YOUR SPA ” Practice Location

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