Provider Demographics
NPI:1417725896
Name:MADDOX, GAVIN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:MADDOX
Suffix:
Gender:M
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 1:2230 ROSALIA DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2256
Mailing Address - Country:US
Mailing Address - Phone:909-533-1614
Mailing Address - Fax:
Practice Address - Street 1:17672 BEACH BLVD STE E
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6836
Practice Address - Country:US
Practice Address - Phone:909-533-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57336225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist