MEDICARE: JOHNNETTE DU RAND KELLY MT, CMLDT

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	23606	CA

General Provider Information

NPI Number	:	1720685639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNETTE DU RAND KELLY MT, CMLDT

Provider Business Mailing Address
First Line	:	116 38TH ST
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-2918
Country	:	US
Telephone Number	:	949-439-0282
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 38TH ST
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-2918
Country	:	US
Telephone Number	:	949-439-0282
Fax Number	:

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

Provider Enumeration Date	:	10/04/2020
Last Update Date	:	10/04/2020

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