Provider Demographics
NPI:1619582350
Name:DIZON, SERGIO (CMT)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:DIZON
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3226 MELANIE RD
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-2627
Mailing Address - Country:US
Mailing Address - Phone:831-854-8918
Mailing Address - Fax:
Practice Address - Street 1:3226 MELANIE RD
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-2627
Practice Address - Country:US
Practice Address - Phone:831-854-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist