MEDICARE: EBONEE TAYLOR LMT

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	482	CA

General Provider Information

NPI Number	:	1629528427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONEE TAYLOR LMT

Provider Business Mailing Address
First Line	:	37 W YOKUTS AVE STE 4
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5727
Country	:	US
Telephone Number	:	510-867-6578
Fax Number	:

Provider Business Practice Location Address
First Line	:	37 W YOKUTS AVE STE 4
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5727
Country	:	US
Telephone Number	:	510-867-6578
Fax Number	:

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

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	02/26/2026

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