Provider Demographics
NPI:1275209314
Name:KIRIAZIS, PATRICIA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:KIRIAZIS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9226 LAKE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-1976
Mailing Address - Country:US
Mailing Address - Phone:619-375-7871
Mailing Address - Fax:
Practice Address - Street 1:8380 CENTER DR STE E
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2952
Practice Address - Country:US
Practice Address - Phone:619-466-6077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA87726OtherMEDICARE
CA78871Medicaid