Provider Demographics
NPI:1609451483
Name:PRADO, ISAIAH KEONI (MT)
Entity Type:Individual
Prefix:
First Name:ISAIAH
Middle Name:KEONI
Last Name:PRADO
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 HOLLYWOOD BLVD APT 3213
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6381
Mailing Address - Country:US
Mailing Address - Phone:323-327-7900
Mailing Address - Fax:
Practice Address - Street 1:6200 HOLLYWOOD BLVD APT 3213
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6381
Practice Address - Country:US
Practice Address - Phone:323-327-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85430225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA85430OtherCALIFORNIA MASSAGE THERAPY COUNCIL