Provider Demographics
NPI:1306412465
Name:TEJADA, MICHAEL (CMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TEJADA
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 E J ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-2719
Mailing Address - Country:US
Mailing Address - Phone:909-238-5152
Mailing Address - Fax:
Practice Address - Street 1:10601 CHURCH ST STE 109
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6894
Practice Address - Country:US
Practice Address - Phone:909-285-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85012225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist