Provider Demographics
NPI:1134668452
Name:YOUR SPA
Entity Type:Organization
Organization Name:YOUR SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTOINETT
Authorized Official - Middle Name:M
Authorized Official - Last Name:CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:32539
Authorized Official - Phone:619-255-0789
Mailing Address - Street 1:3609 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4105
Mailing Address - Country:US
Mailing Address - Phone:619-255-0789
Mailing Address - Fax:
Practice Address - Street 1:3609 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4105
Practice Address - Country:US
Practice Address - Phone:619-255-0789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32539302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization