Provider Demographics
NPI:1679949754
Name:MOLINA, LUIS (MASSAGE THERPIST)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:
Last Name:MOLINA
Suffix:
Gender:M
Credentials:MASSAGE THERPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 CANDLEWOOD ST
Mailing Address - Street 2:SUITE 19B
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1925
Mailing Address - Country:US
Mailing Address - Phone:818-714-9051
Mailing Address - Fax:562-272-7303
Practice Address - Street 1:5150 CANDLEWOOD ST
Practice Address - Street 2:SUITE 19B
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1925
Practice Address - Country:US
Practice Address - Phone:818-714-9051
Practice Address - Fax:562-272-7303
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41489174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA41489OtherMASSAGE LICENSE