Provider Demographics
NPI:1558086512
Name:VALDEZ SEGURA, LUIS FERNANDO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:VALDEZ SEGURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 N BRADFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5609
Mailing Address - Country:US
Mailing Address - Phone:714-818-2768
Mailing Address - Fax:714-646-9492
Practice Address - Street 1:138 N BRADFORD AVE
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-5609
Practice Address - Country:US
Practice Address - Phone:714-818-2768
Practice Address - Fax:714-646-9492
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8902OtherCALIFORNIA MASSAGE THERAPY COUNCIL