MEDICARE: LYSSA LYNN UCHIDA MT

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	225700000X	Massage Therapist	37859	CA

General Provider Information

NPI Number	:	1194214056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYSSA LYNN UCHIDA MT

Provider Business Mailing Address
First Line	:	702 W HAMILTON PL APT 8
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-6371
Country	:	US
Telephone Number	:	310-293-9382
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 S CATALINA AVE STE E
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3622
Country	:	US
Telephone Number	:	310-293-9382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2018
Last Update Date	:	05/07/2018

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