Provider Demographics
NPI:1497229652
Name:BEDOLLA, TIFFANY (ANMT CMT)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:
Last Name:BEDOLLA
Suffix:
Gender:F
Credentials:ANMT CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 K ST STE 514
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-3408
Mailing Address - Country:US
Mailing Address - Phone:630-697-7429
Mailing Address - Fax:
Practice Address - Street 1:717 K ST STE 514
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-3408
Practice Address - Country:US
Practice Address - Phone:630-697-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69157225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist