Provider Demographics
NPI:1598854531
Name:MASSOUD, JOHN (ATC, LMP, NCTM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MASSOUD
Suffix:
Gender:M
Credentials:ATC, LMP, NCTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HIDDEN CREEK LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22471 ASPAN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1642
Practice Address - Country:US
Practice Address - Phone:949-583-1797
Practice Address - Fax:949-586-5701
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500748-05225700000X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer