Provider Demographics
NPI:1649025362
Name:CALDERA, KRYSTAL (LMT)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:
Last Name:CALDERA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:LONGORIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:17644 BRIGHTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-5931
Mailing Address - Country:US
Mailing Address - Phone:951-579-0758
Mailing Address - Fax:951-622-1110
Practice Address - Street 1:38397 INNOVATION CT STE 103
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2631
Practice Address - Country:US
Practice Address - Phone:951-579-0758
Practice Address - Fax:951-622-1110
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57160225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist