MEDICARE: YANDI CAKRASENJAYA LMT, MMP

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	MT.0023692	CO

General Provider Information

NPI Number	:	1811640832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YANDI CAKRASENJAYA LMT, MMP

Provider Business Mailing Address
First Line	:	359 E ENTERPRISE DR STE 7
Second Line	:
City	:	PUEBLO WEST
State	:	CO
Zip	:	81007-1443
Country	:	US
Telephone Number	:	720-600-9994
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 W US HIGHWAY 50
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81008-1606
Country	:	US
Telephone Number	:	720-600-9994
Fax Number	:

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

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/27/2026

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